Q Bank: Gerontology & Professional Role

The nurse practitioner is performing a funduscopic exam on a 68-year-old man and notes pale gray spots with irregular borders. It is noted in the patient's record that he has a history of uncontrolled type 2 diabetes mellitus. Which of the following is the priority action?

Data indicates that educating patients on the importance of tight glycemic control is critical because the achievement of even a modest 1% reduction in the A1C level significantly reduces the risk for the onset of this vascular disease (by upwards of 35%) and can slow the progression of an existing diabetic retinopathy (by up to 25%).

A 16-year-old boy presents to the nurse practitioner for a physical. Based on the most common cause of death in this age group, which of the following statements should be emphasized to the patient?

"It is important for you to wear your seatbelt" Motor vehicle crashes are the leading cause of death in people aged 13-19 in the United States. According to Healthy People 2030, unintentional injuries are the leading cause of death for people 15-24 years of age. Nurse practitioners should focus on primary prevention within this age group by educating patients on using seat belts, reducing driving speed, and protecting pedestrians. While all of the given statements are important for the patient's health and well-being, the patient is at the greatest risk of injury or death due to a motor vehicle crash.

A 92-year-old man with multiple comorbidities presents to the clinic with his daughter with concerns of a worsening tremor. She states that the patient has developed a tremor in his right hand and arm. The patient reports stiffness of the arm and slowed movement but is without pain. He reports no difficulty performing his activities of daily living. The nurse practitioner's leading differential is Parkinson disease. Which of the following statements best conveys the appropriate management plan to the patient and his daughter?

"Lets discuss the risks and benefits of starting medications to help with your tremor" Parkinson disease is a slowly progressing neuromuscular disorder that leads to resting tremors, bradykinesia, and rigidity. Upon assessment, the resting tremor is often unilateral and resolves with intentional movement. The goal of management is to control the symptoms, but this does not slow progression of the disease. The most effective medication for management is carbidopa-levodopa, but it is also associated with significant dyskinesias and involuntary motor movements. Because of these significant side effects, the nurse practitioner should discuss the risks and benefits associated with therapy. This allows for the patient (and in many cases, the family) opportunity to participate in shared decision-making

A 72-year-old woman presents to the clinic for a follow-up on her recent bone density scan. Her T-score was −2.9, indicating she has osteoporosis. Which of the following statements would be most appropriate to teach the patient about the use of risedronate (Actonel)?

"This should be taken first thing in the morning with plain water and at least 40 minutes before consuming any food" Risedronate (Actonel) belongs to the bisphosphonate class of drugs that is used for the treatment of osteoporosis. Bisphosphonate therapy is indicated when a patient has a pathological fracture, a low-impact hip fracture, or osteoporosis. A dual-energy X-ray absorptiometry (DXA) T-score of −2.5 or less in the total hip, femoral head, or spine indicates osteoporosis. Bisphosphonates work by inhibiting osteoclast-induced bone resorption and increasing bone density. To ensure absorption of the medication in the intestines, oral bisphosphonates should be taken first thing in the morning with plain water and at least 40 minutes before consuming any food. These medications are excreted in the urine, but no dosage adjustments are needed if creatinine clearance is above 35 mL/min. Bisphosphonates have a 10-year long half-life, thus, after 3 years, a new DXA bone scan may be obtained. If the T-score has risen above −2.5 and there is a low risk for fractures, the bisphosphonate can be discontinued.

A 75-year-old man presents with right-sided weakness and facial droop. The nurse practitioner is appropriately concerned for a potential stroke. Which of the following findings is most concerning for a hemorrhagic stroke?

A blood pressure of 220/100 Stroke is the fifth leading cause of death in the United States. The two subtypes of stroke are ischemic and hemorrhagic. Uncontrolled hypertension is the most common cause of a spontaneous intracerebral bleed, making a blood pressure of 220/100 concerning for hemorrhagic stroke. Hemorrhagic stroke often occurs when a micro aneurysm from untreated hypertension spontaneously bursts, causing bleeding into the brain. Other causes include bleeding disorders, anticoagulant use, cocaine and alcohol use, vasculitis, and cerebrovascular aneurysms and malformations. Patients with hemorrhagic stroke will often have an initial episode of loss of consciousness, typically followed by excessive vomiting and headache. After initial symptoms start, rapidly progressive neurological deficits will emerge. Diagnosis is often confirmed by use of a non contrast computed tomography scan of the head. Treatment largely revolves around close blood pressure control and reversal of coagulopathies. Surgical evaluation of the hematoma may be necessary.

A 63-year-old man presents to the clinic with a sudden, painless loss of vision in his right eye. Which finding during a funduscopic exam would make the nurse practitioner suspect a central retinal artery occlusion?

A cherry red spot and a pale swollen retina are classic signs of central retinal artery occlusion The central retinal artery carries blood to the inner retina and optic nerve. If a nurse practitioner suspects a central retinal artery occlusion, the patient should be taken to the closest hospital with a stroke center. There are two types of retinal artery occlusions: central and branch. Both occlusions present with a sudden painless loss of vision in one eye. In general, there is a poor prognosis of regaining sight in patients with retinal artery occlusion, but nurse practitioners who can identify signs and get patients to hospitals for proper treatment within 24 hours of symptom onset help improve the chances of a patient regaining vision.

A 67-year-old man presents with new bilateral leg pain. During the initial intake interview, the nurse practitioner learns that the pain increases during activities, such as walking the stairs, but is relieved almost immediately with rest. Which of the following is the most appropriate next step in management?

A cost-effective next step to assess for peripheral artery disease involves ordering an ankle-brachial index Peripheral artery disease occurs when occlusive atherosclerotic lesions develop in the extremities. It occurs in 30% of patients who are ≥ 50 years old and have diabetes mellitus or a history of tobacco use. Approximately two-thirds of patients with peripheral artery disease either have no symptoms or are asymptomatic. If symptoms do occur, it usually presents as pain due to a decrease in blood flow that cannot keep up with the increased demands of exercise. Claudication pain is described as cramping that primarily occurs in the calf muscles. Although it is usually reproducible, it varies from day to day and is called intermittent claudication. The pain is relieved by rest. A cost-effective next step to assess for peripheral artery disease involves ordering an ankle-brachial index. This test can be performed at the bedside. It is performed by taking the ratio of systolic blood pressure detected by Doppler examination at the ankle and comparing it to the brachial artery pressure.

COPD:

A disease of airflow obstruction manifested by respiratory symptoms, including cough, sputum production, and dyspnea. Exacerbations with worsening symptoms are characteristic of the disease. COPD is the fourth leading cause of death in the United States, affecting more than 10 million people. The severity of COPD can be assessed using the COPD Assessment Test (CAT). This assesses eight facets of COPD, including symptoms, confidence in leaving the home, and ability to participate in home activities. A lower score is suggestive of low symptoms and low risk, while a higher score correlates with worsening disease and risk for exacerbations. A CAT score < 10, coupled with zero or one recent exacerbation and no hospitalizations, places a patient in Group A and is consistent with mild, well-controlled disease. A SABA or LABA is appropriate in this case.

Nurse practitioners who employ an evidence-based disease management approach for their patients realize that appraisal of the evidence requires the reader to evaluate the level of evidence as well as the number of studies available that have examined the specific clinical issue of concern. Which of the following research designs is considered the highest level of evidence when determining cause-and-effect relationships?

A randomized controlled trial A randomized controlled trial is a research design that uses a random process to assign participants to either an experimental or control group. The intervention group receives the treatment or intervention being studied, while the control group does not. This allows researchers to compare the outcomes of the two groups and determine whether the intervention had a significant effect. Randomized control trials are considered the research design that yields the highest level of evidence for establishing causation because of their ability to control for confounding factors and establish a cause-and-effect relationship between an intervention and an outcome

A patient is a participant in a clinical research study in which half of the patients receive the study drug and half of the patients receive a placebo drug. The patients do not know to which group they are assigned. Which of the following does this represent?

A randomized controlled trial This is an experimental research design that randomly assigns the study participants into treatment and control groups. A randomized controlled trial (RCT) is used to test a new treatment or intervention. Common types of RCTs include placebo-controlled studies and active-control studies. In a placebo-controlled study, the experimental group receives the new treatment and the control group receives a placebo. In an active-control study, the control group receives the current standard of care instead of a placebo. Blinding is a research technique used to decrease bias and can be single or double. In single blinding, the study participants do not know to which group they are assigned. In double blinding, neither the study participants nor the researchers know to which group the participants are assigned

A 76-year-old man presents to the office for a routine physical exam. During the skin exam, the nurse practitioner notices a lesion that is < 1 cm in size on the head. Upon questioning, the man states he spent a lot of his career outdoors in the sun. Which of the following exam findings would make the nurse practitioner suspect actinic keratosis?

A red, pink, or brown lesion that is rough with a yellow scale on the top These lesions are usually painless and asymptomatic. They are most commonly seen on sun-exposed areas, including the head, neck, arms, and hands. AK is considered a premalignant lesion and can progress to squamous cell carcinoma.Risk factors for AK include age over 40 years, sun exposure, and fair complexion. It is more common in men than women. Diagnosis is often clinical and can be confirmed on a physical exam. If there is a high suspicion for carcinoma, a biopsy should be completed. The first-line treatment is cryotherapy. Patients with AK should be educated to wear sunscreen and protect their skin from the sun

A nurse practitioner is looking at research evidence to find an effective treatment plan for endometriosis. Which of the following research methods presents the strongest evidence?

A systematic review of randomized controlled trials (RCTs) This presents the strongest evidence by using the most rigorous scientific method. An RCT is an experimental research design used to test a new treatment or intervention. It randomly assigns study participants into control and treatment groups, which minimizes potential bias. A systematic review of RCTs summarizes controlled studies about a specific topic and provides the highest level of evidence regarding treatments or interventions. A seven-level research hierarchy of evidence pyramid visually ranks the quality of the evidence for different study types. The base of the pyramid represents the least reliable study type, and the apex of the pyramid represents the most reliable study type. Systematic reviews of RCTs are found at the top of the hierarchy of evidence and are used to establish the standard of care for clinical guidelines. A meta-analysis is often included in a systematic review and is defined as a statistical method of combining data from different studies.

A 62-year-old man with type 2 diabetes mellitus is diagnosed with stage 2 hypertension. He was started on enalapril (Vasotec) in addition to recommendations for lifestyle modifications. According to the American Heart Association and American College of Cardiology (AHA/ACC) guidelines, which of the following is the goal blood pressure for this patient?

According to the AHA/ACC guidelines, the goal blood pressure in patients is < 130/80 mm Hg

An 82-year-old patient presents to the clinic for evaluation of a crusty, raised skin lesion on the face. The nurse practitioner identifies the lesion as actinic keratosis and suggests treatment with cryotherapy. Which of the following is important to discuss with the patient regarding this diagnosis?

Actinic keratosis (AK) is a common precancerous lesion that is caused by cumulative UV exposure Coloration spans red, pink, or brown and a rough, yellow scale is common. If left untreated and exposed to additional UV light, it can progress to squamous cell carcinoma. Dual treatment with cryotherapy (first-line therapy) and topical agents such as 5-fluorouracil are shown to be more effective than monotherapy.AK is usually painless and asymptomatic. It is most commonly seen on sun-exposed areas, including the head, neck, arms, and hands. Risk factors for AK include age over 40 years, sun exposure, and fair complexion. It is more common in men than women. Diagnosis is often clinical and can be confirmed on a physical exam. If there is a high suspicion for progression to squamous cell carcinoma, a biopsy should be completed. Patients with AK should be educated to wear sunscreen and protect their skin from the sun.

A 76-year-old man presents to the urgent care clinic reporting sudden pain and redness in his right eye. He states that it has gotten progressively worse in the last hour. He reports blurry vision and seeing "rings." He tried using over-the-counter eye drops, but they did not alleviate his symptoms. During the funduscopic exam, the following findings are noted: a dilated right pupil with a hazy cornea, and eye firm to the touch. His left eye is unaffected and benign on exam. Which of the following is the most likely diagnosis?

Acute closed-angle glaucoma Often presents as a sudden onset of pain in one eye accompanied by decreased visual acuity. Another common symptom is the presence of halos or seeing rings. Acute closed-angle glaucoma is caused by increased intraocular pressure and is an emergent situation to avoid permanent vision loss. Emergency referral is warranted to reduce intraocular pressure to avoid permanent vision damage or loss.

A 65-year-old man presents to the clinic today for a hospital follow-up. He was recently diagnosed with a deep vein thrombosis and started on warfarin (Coumadin). Upon evaluation today, his INR is 11. Which of the following is the priority action?

Administer vitamin K A therapeutic INR level to inhibit clot formation is 2-3. Since the mechanism of action is to prevent clotting, patients on warfarin (Coumadin) are at high risk of bleeding and need to be monitored closely for elevated INR and signs of bleeding. The antidote for warfarin (Coumadin) overdose is to replenish vitamin K either orally (A) or intravenously, as warfarin inhibits the synthesis of clotting factors by the liver specifically by depleting the vitamin K stores. Similarly, patients taking warfarin (Coumadin) should be cautious of vitamin K-rich foods, like dark leafy greens and some berries, which can augment its effects. Warfarin (Coumadin) can be used post-surgically for orthopedic patients and for patients with a history of deep vein thrombosis (DVT), mechanical valves, and thromboembolism to prevent clotting. To monitor its activity, patients on warfarin (Coumadin) have an INR evaluated daily. Once a therapeutic dose is established, INR testing intervals can be extended. The effects of warfarin (Coumadin) can last 2-5 days, but initial anticoagulation can be seen after 24-72 hours of dosing.

A 21-year-old woman presents to the clinic today with her 65-year-old father. The woman is visibly upset, as she describes that her father is becoming increasingly confused and recently ran several red lights because he stated they were green. She is requesting that the nurse practitioner revoke his license for his safety. Which action would be the most appropriate for the nurse practitioner to perform next?

Administering a Montreal Cognitive Assessment (MoCA) To assess the patient's reported cognitive decline is the most appropriate initial action. The MoCA is a rapid screening for mild cognitive dysfunction. Orientation, executive functioning, attention, memory, language, visuoconstructional skills, conceptual thinking, and calculation are among the cognitive areas assessed.

A 65-year-old man with a history of hyperlipidemia and coronary artery disease states presents to the clinic. He previously attempted to increase his physical activity by going on daily walks but did not consistently follow his routine. Today he states, "I've joined the gym near my house. They have a chair aerobics class, and I've been going twice a week!" The nurse practitioner replies, "Once you make up your mind to do something, you get it done!" Which of the four responses to change talk does this reflect?

Affirmation Motivational interviewing, a technique for supporting patients to engage in more healthful behaviors through engagement in conversations about change, originated in the context of treatment for substance use disorders. The acronym OARS, which stands for open question, affirmation, reflection, and summary, provides a framework for responding to change talk from the patient. Affirmation responses positively recognize patient comments on their intent to change.

Which of the following cultures may practice the belief that illness is brought on by bad spirits enticed by living against natural law?

American Indian American Indian culture places emphasis on disease being driven by bad spirits. Most American Indian tribes believe that illness is caused by an imbalance between good and evil spirits. Many use traditional healers and spirituality to help cleanse themselves of illness. Another common tradition is the use of a medicine pouch, which is a small bag worn by an individual to aid in healing. Traditional practices should be respected and incorporated into modern treatment at the patient's request. Practices and beliefs may vary depending on the patient's affiliated tribal group, as differences exist between tribes. Remember that any cultural belief can be a broad generalization and should never be used to stereotype individuals.

A nurse practitioner is completing documentation at the end of a patient's office visit. Which of the following codes is used to document an incision and drainage of the patient's abscess?

An incision and drainage of an abscess is a procedure documented with a CPT code The CPT is a comprehensive list that assigns codes to medical services and procedures. These codes are used as a common language among health care professionals to streamline reporting and claims. The specific CPT code for an incision and drainage of this patient's abscess would be further determined by the location and complexity of the procedure.CPT codes were developed and are routinely updated by the American Medical Association. Each code is composed of five characters, including numbers or a combination of numbers and letters. There are over 10,000 CPT codes currently used. Other common outpatient medical services and procedures include electrocardiogram interpretation, cerumen impaction removal, and Pap smear.

The nurse practitioner is providing education to a 72-year-old patient who occasionally takes an over-the-counter antacid. The nurse practitioner assesses that the patient understands the instructions when he states which of the following?

Antacids are most effective when taken prior to a meal

Which of the following is not considered a secondary prevention method for a 50-year-old patient?

Asking a patient about their smoking use This is recommended at every visit, but it is not a form of screening or detecting a disease.

Is the most common dysrhythmia and is associated with increased age?

Atrial Fibrillation The atrial tissue is associated with rapid electrical conduction due to its ability to depolarize and repolarize quickly, which is evidenced by the rapid heart rate associated with atrial fibrillation. These inappropriate electrical signals do not travel to the AV node, and thus the atria and ventricles do not contract in sync. Atrial fibrillation is categorized based on its duration (< 1 week, < 1 year, long term, and refractory to treatment). Triggers include caffeine, stress, alcohol, and emotion. Patients with cardiovascular disease, a history of cardiac surgery, hypertension, and diabetes are also at increased risk for developing atrial fibrillation.

The nurse practitioner is caring for a patient who has a terminal cancer diagnosis. The patient has expressed interest in stopping all treatment and transitioning to hospice care. The family pulls the nurse practitioner aside and states that they would like his treatment to continue instead. The nurse practitioner understands that this would violate which ethical principle?

Autonomy The principle of autonomy allows the patient to make their own decisions once educated. As long as the patient is rational and competent, they should always be allowed to make decisions regarding their own health care. If the nurse practitioner pursued treatment against the patient's wishes, this would violate their autonomy

Which act required nurse practitioners to acquire a National Provider Identifier in order to bill Medicare?

Balanced Budget Act Medicare is a government-based health insurance program that is geared toward patients over 65 years old, those with disabilities, and people with end-stage kidney disease who require dialysis. In 1997, Congress passed the Balanced Budget Act, which required nurse practitioners to directly bill Medicare. In order to bill Medicare, clinicians must obtain a National Provider Identifier (NPI). The state the nurse practitioner is practicing in will determine the nurse practitioner's collaboration agreement and services that may be provided.

A nurse practitioner is preparing to evaluate an elderly patient using the Katz Index of Independence in Activities of Daily Living. Which of the following tasks, if exhibited by a patient, is not considered a scorable component of this evaluation tool?

Being able to prepare and plate the food themselves The Katz Index of Independence in Activities of Daily Living is a multipoint scale with independent activities rating 1 point and dependent activities scoring 0 for that variable. A full 6 points is considered fully independent, with 4 points considered moderate impairment and 2 or fewer considered severe functional impairment or limitation. An individual must be able to get food from the plate into their mouth without help in order to score 1 point for the task. However, they are not required to be able to prepare and plate the food themselves, making this the correct answer. Activities of daily living or independent activities of daily living are a subcategory of functional ability (capacity) testing designed to assess the independence and self-maintenance of the examinee. When there are questions about a need for care or support, the nurse practitioner may test a patient or refer them for testing to further evaluate the patient's needs.

Which of the following scenarios is associated with a higher relative risk for episodes of physical child abuse?

Child abuse is more predominantly seen in households of lower socioeconomic status

A new mother is concerned she will be unable to pay for her infant's well-baby visits. She currently has no private health insurance and does not qualify for Medicaid. Which of the following programs could the nurse practitioner suggest to obtain health insurance coverage for the infant?

Children's Health Insurance Program (CHIP) The nurse practitioner could suggest the Children's Health Insurance Program (CHIP) to obtain health insurance coverage for the infant. CHIP is a program that provides coverage for children in families that do meet the reduced income criteria for Medicaid but are unable to afford private insurance coverage. Like Medicaid, CHIP is also funded at state and federal levels. Each state sets specific requirements for CHIP eligibility and benefits based on federal guidelines. Some states provide CHIP through a Medicaid expansion benefit, while other states offer CHIP as a separate benefit. Select CHIP benefits are mandatory under federal law, including well-baby and well-child visits, immunizations, behavioral health services, and dental care.

A 74-year-old woman presents to the office with dull left lower quadrant abdominal pain. She reports the pain started yesterday after she finished dinner and has gotten progressively worse. She reports several episodes of vomiting and states that "she can't keep anything down." Her vital signs today are a T of 100.4°F, BP of 110/72 mm Hg, HR of 96 bpm, and SpO₂ of 100% on room air. The patient reports severe pain upon palpation of the left lower quadrant. These findings are most consistent with which of the following diagnoses?

Diverticulitis Diverticulitis is often associated with low-grade fever and left lower quadrant pain. Diverticulitis is an infection of the outpouching of the colonic wall. Nearly 70% of people in the United States will experience diverticulosis by the age of 80 years. Risk factors include age, a low-fiber diet, a sedentary lifestyle, and prior instances of diverticulitis. The pain is described as dull and typically occurs in the left lower quadrant pain. The role of antimicrobials in uncomplicated diverticulitis is not well established. If selecting to use antimicrobials, the nurse practitioner should cover for both anaerobes and gram-negative bacteria.

A 68-year-old woman presents to the office for evaluation of potential skin cancer and an overall skin check. Upon exam, the nurse practitioner notices that the patient's skin appears tented, and she seems mildly dehydrated. The patient is offered water during the exam but refuses. She states she is Muslim, and since it is Ramadan, she must wait until sundown to eat or drink. What is the most appropriate way to proceed with this visit?

During Ramadan, people of Muslim faith do not eat or drink from sunrise to sunset. This is a 30-day period during which all oral consumption must be done during the sundown to sunrise time frame. Although this patient may be dehydrated, she still has autonomy and can make decisions for herself. Findings should be documented in a note

You are seeing a 65-year-old man in the office today for medication reconciliation. He has a medical history of hypertension, asthma, and obesity and takes numerous herbal supplements. Based on this patient's comorbidities, which of the following herbal supplements should be prioritized in conversation with the patient today?

Echinacea Echinacea, a flowering plant native to North America, is known to be used for its immune-boosting properties. Conflicting findings have been reported regarding its efficacy in managing asthma symptoms. Echinacea should not be used in place of rescue medications, and the nurse practitioner should further discuss the use of this supplement for the self-management of asthma symptoms during the visit.

A 65-year-old woman was recently enrolled in Medicare part A and B. Which of the following is covered under Medicare part B?

influenza vaccine Medicare is a government-based health insurance program that is targeted at people ≥ 65 years old, those with disabilities, and people with end-stage kidney disease who require dialysis. There are several different plans that qualified adults may enroll in. Medicare part B covers the cost of outpatient care, certain medical services and medical equipment, and preventable health services. Obtaining the annual influenza vaccine would be covered by Medicare part B. There is a monthly premium that Medicare charges patients to have part B coverage

A 78-year-old man presents to the clinic for a follow-up after an emergency department visit for acute bronchitis. He reports he did not fill his discharge prescriptions because he could not pay for them. The man states, "My grandson borrowed my debit card last month for an emergency and hasn't returned it." Which of the following types of elder mistreatment might this indicate?

Exploitation Exploitation is the illegal or improper use of an older adult's funds, property, or assets. The scenario presented involves the grandson of the older adult borrowing his debit card for an emergency but not returning it, which has resulted in the older adult being unable to fill his prescriptions due to lack of funds. This suggests that the grandson may have taken advantage of the older adult's resources and is thus a form of financial exploitation

A 73-year-old woman with a long-standing history of bipolar disorder and prescribed lithium presents to the clinic today with her daughter. The daughter states, "Something about my mom seems off today. She keeps saying she has nausea and a headache." Which of the following assessment findings would be most concerning?

Gross Tremor Lithium, an antimanic agent, is approved for the treatment of bipolar disorder and is used off-label for the management of hypomania, bipolar major depressive disorder, and unipolar major depressive disorder. Side effects include but are not limited to sedation, confusion, acne, dyspepsia, hypercalcemia, and hyperthyroidism. Careful monitoring of serum lithium levels is indicated, as the medication has a narrow therapeutic window of 0.6 to 1.2 mEq/L, and lithium toxicity can ultimately result in seizure, coma, and death. In cases of severe lithium toxicity, it is common to see gross or coarse tremors, vomiting, slurred speech, confusion, and lethargy. Thus, this would be the most concerning assessment finding listed.

A nurse practitioner is counseling her patient, who is worried about the results of her recent skin biopsy. The nurse practitioner informs the patient that she will call her with the results as soon as she sees them. The following week, she calls the patient and informs her that her skin biopsy was benign. Which ethical principle is being upheld in this scenario?

Fidelity Fidelity involves being truthful and loyal within the nurse practitioner and patient relationship. In the given scenario, the nurse practitioner demonstrated fidelity by following through on their promise to their patient to follow up on biopsy results. The nurse practitioner was loyal to their patient and reaffirmed the nurse practitioner and patient relationship

A 68-year-old patient presents with a new unsteady gait and episodes of periodic confusion. Which of the following diseases is not associated with neurologic dysfunction?

Folate deficiency Alzheimer disease is associated with myriad neurologic symptoms, including periodic confusion and forgetfulness that increases as the disease progresses. Hypothyroidism can affect the central and peripheral nervous system including cognitive impairment and peripheral neuropathy. Severe hypothyroidism can result in a myxedema coma. Wernicke encephalopathy is a clinical syndrome most commonly associated with alcohol use. The classic triad of symptoms includes ophthalmoplegia, confusion, and ataxia

A 73-year-old man with a medical history of diabetes mellitus type 2 and uncontrolled hypertension presents for 2 weeks of oliguria that seems to be worsening. He also notes fatigue, itching, and swelling in the legs. The nurse practitioner suspects chronic kidney disease. Which of the following labs is most appropriate to order for evaluation of kidney function?

Glomerular filtration rate (GFR) Glomerular filtration rate (GFR) is the best measure of kidney function. It is the rate at which the glomeruli in the kidney filter toxins from the blood (such as urea and creatinine) and excrete them in the urine. In acute kidney injury or chronic kidney disease (CKD), the GFR decreases, causing waste to build up in the blood. GFR is calculated using age, race, sex, and creatinine. The GFR is used to stage CKD and determines if dialysis is necessary. Diabetes, uncontrolled hypertension, smoking, drug use, obesity, chronic infection, nephrotoxic drugs, and autoimmune disease are risk factors for developing poor kidney function and CKD.

Which of the following Federal acts required the adoption of electronic health records within both inpatient and outpatient settings?

The Health Information Technology for Economic and Clinical Health (HITECH) Act Required the use of computerized electronic health records (EHR) to improve patient safety, health care quality, and continuity of care across a patient's health care team. It was signed in 2009.

The nurse practitioner is seeing a 76-year-old man in the office for his annual physical. Which statement made by the patient would prompt further investigation for potential cataracts?

Having difficulty seeing things at a distance Adults presenting with cataracts will usually report bilateral vision changes. These changes may include difficulty seeing things at a distance when compared to things close by due to the myopic shift that occurs with cataracts. A classic problem that patients present with is the increased difficulty with night driving. They may also have foggy or cloudy vision and the presence of bilateral leukocoria on examination. Radiation therapy and glucocorticoid treatment may induce cataracts, but a majority develop with age. The only curative treatment for cataracts is removal and replacement of the occluded crystalline lens, a minor and common surgery.

Which of the following is an example of how a nurse practitioner can advocate for a school-age patient with a learning disability?

Help the family brainstorm a list of questions and requests that they can discuss at a meeting with the designated school psychologist

Which of the following populations traditionally believe that the evil eye is responsible for illness?

Hispanic

A 78-year-old woman presents to the clinic with her daughter, the primary caregiver. Her daughter notes that the patient has seemed more forgetful than usual. Which of the following scenarios would be concerning for potential Alzheimer disease?

If she has had a steady decline in memory over the past 2 years Alzheimer disease is the most common cause of dementia in older adults. Pathophysiology is largely unknown. It typically presents during older age, but early symptoms can onset in a patient's 60s. Rare familial cases can occur as young as the age of 50. Typically, presentation is a slow, steady decline in mental status over a several-year period. Other common signs are loss of judgment, apraxia, visual disturbances, sleep disturbances, and seizures

A primary care practice is reviewing policies on how to handle cases of sexual abuse and rape. Which of the following is true regarding mandatory reporting?

In the United States, it is mandatory that the sexual assault of minors or older people be reported to law enforcement Reporting communicable diseases or reportable assault cases is a clear exception to patient confidentiality laws. Clinicians should be aware of national, state, county, and local regulations regarding reporting. Reportable communicable diseases are generally reported to the county or state health department. Assault and abuse cases requiring reporting (such as minors and older patients) must be disclosed to law enforcement for further action.

Secondary prevention interventions:

Include screening with the goal of early detection of disease. Examples include colonoscopies, blood pressure screening, and routine mammograms.

A 60-year-old patient with a medical history of COPD presents to the clinic for follow-up of an acute upper respiratory infection diagnosed 1 week ago. Today he reports progressive respiratory symptoms, and the nurse practitioner diagnoses him with a COPD exacerbation. Which of the following is not considered criteria for antibiotic treatment for this patient?

Increased cough A COPD exacerbation is defined as an acute episode (< 14 days) of worsening respiratory symptoms accompanied by manifestations of local and systemic inflammation. These episodes may be triggered by viral infection, bacterial infection, or environmental factors. COPD exacerbations are classified by GOLD report criteria as mild, moderate, or severe. These criteria assess dyspnea, respiratory rate, heart rate, resting oxygen saturation, and C-reactive protein levels. Antibiotic therapy should be prescribed to patients with at least two of the three cardinal symptoms: increased dyspnea, increased sputum purulence, and increased sputum volume. Increased cough is not included in this criteria. In addition to patients with two of the cardinal symptoms, antibiotics are also indicated for patients with COPD exacerbation who require hospitalization or ventilatory support and those with clinical presentations consistent with pneumonia. Antibiotic treatment for COPD exacerbations is determined by risk factors and bacteria resistance patterns in the area. These may include amoxicillin-clavulanate, macrolides, second- or third-generation cephalosporins, or respiratory fluoroquinolones. Typical antibiotic dosing regimen is 5 days for patients who are clinically improving. Nonantibiotic treatments commonly used in the outpatient setting to treat COPD exacerbations include bronchodilators and systemic corticosteroids.

Which of the following Erikson stages would represent an 11-year-old boy who is proud of getting As on his report card?

Industry versus inferiority Industry versus inferiority is the fourth Erikson stage (about 6 to 12 years old) and is related to children gaining competence and taking initiative or pleasure in their work. The definition of inferiority is a state in which an individual feels discouraged, inadequate, or incompetent after receiving feedback on their work. The Erikson stages were based on the premise that as children progress through these psychosocial stages, certain traits become salient.

A new patient presents to the office. While the nurse practitioner is reviewing his medical history, he states that he is a member of The Church of Jesus Christ of Latter-Day Saints. Which of the following is in alignment with what the members of this community observe?

not drinking hot tea or coffee The Church of Jesus Christ of Latter-Day Saints is home to members of the Mormon faith. They observe strict purity laws such as not consuming alcoholic beverages or tobacco, not drinking hot tea or coffee (B), and abstaining from sexual intercourse until marriage. The founder of the Church, Joseph Smith, stated in his teachings that wine should be the only drink other than water to keep the body pure.

A nurse practitioner is preparing for a possible office procedure for an adult patient. Discussion with the patient prior to the procedure includes information regarding alternative options for treatment. Which of the following terms characterizes the nurse practitioner's conversation with the patient?

Informed consent Informed consent is a legal discussion between the nurse practitioner and a patient regarding a procedure or treatment. This process is based on the ethical principle of autonomy. Discussion of alternative options for treatment by the nurse practitioner is a necessary part of informed consent. Other required components include the patient's diagnosis, the risks and benefits of the proposed procedure, and the risks if the patient refuses the procedure. A procedure cannot occur until the patient is deemed competent and has provided voluntary consent. Competence is defined as the mental capacity to understand the procedure and make an informed decision to proceed with, or refuse, the recommended intervention. Informed consent should contain language that is easy to understand and be documented in the medical record. Research shows that providing patients with written materials increases their understanding of the procedure and empowers the patient in the shared decision-making process. A certified medical interpreter should be used if the patient's primary language differs from the nurse practitioner's primary language. Family members should not translate medical information for the patient due to the risk of relaying incomplete information.

Diabetic retinopathy:

Is one of the most common causes for vision impairment and vision loss in diabetic adults. The two primary risk factors are duration of time with the diagnosis of diabetes and poor glycemic control. Regular eye exams are integral for diabetic patients, and even more important for patients who are persistently hyperglycemic. Abnormal fundoscopic findings that associate with diabetic retinopathy include cotton-wool spots, or intra-retinal infarcts that can present as gray spots with irregular borders. These are indicative of progressive damage to the retinal vessels and If tight glycemic control is not established, vision loss can occur. In addition to monitoring A1C levels, blood pressure and serum lipid levels should be closely monitored

A 43-year-old man presents for a presurgical visit for an appendectomy. His father accompanies him to the visit. The patient is of Asian descent. Which of the following actions offers the most culturally sensitive approach to completing this office visit?

It is important to address the needs and questions of the father or head of the family along with those of the patient Informed consent and patient wishes are more important than all but the most emergent of care. In a pre-surgical visit, even an urgent one, addressing a patient's needs and the concerns of their family is well within a nurse practitioner's scope of practice and allows for a good therapeutic relationship

A 67-year-old woman presents with reports of joint pain in her right hand. She states that she wakes up in pain but that it goes away once she moves her hand around. During the assessment, the nurse practitioner notes a bony prominence on the woman's right index finger at the distal interphalangeal joint and orders an X-ray of the hand. Which finding would support the suspected diagnosis?

Joint space narrowing While X-rays are typically normal early in the disease process for osteoarthritis, joint space narrowing supports the diagnosis. The diagnosis of osteoarthritis is based on the patient history, presentation, and clinical manifestations. Patients will often present with unilateral joint pain that worsens in the morning but improves with use. The joint pain will also be worsened with use and relieved with pain. Osteoarthritis does not present with systemic symptoms such as fever or weight loss. The presence of Heberden or Bouchard nodes is indicative of osteoarthritis. X-ray findings of the impacted joint may include joint space narrowing and osteophyte formation.

Older patients may present with atypical symptoms in response to certain infections. Which of the following is the least likely diagnosis to produce atypical symptoms in this age population?

Lung cancer Lung cancer tends to present with a stereotypical dry cough, regardless of age. Any patient presenting with a cough should have a respiratory exam. In older patients, the nurse practitioner should have a low threshold for ordering radiographs and advanced imaging, such as a chest CT, given the difficulty in differentiating rib fractures or lung cancer with physical examination alone. Consolidation, alteration in radiographic absorption through regions of the lung, or suspicious lesions should be further evaluated with advanced imaging. The median age of patients with newly diagnosed non-small cell lung cancer is 65.

A 28-year-old woman presents for her annual physical exam. She has no significant medical history and no new concerns. When the nurse practitioner prepares to perform the physical exam, she states that she does not feel comfortable changing into the medical gown due to her Muslim faith. What would be the best course of action for the nurse practitioner to take?

perform a modified physical exam over clothing

A family decides to temporarily move their 89-year-old mother into a skilled nursing facility after a hospitalization. The nurse practitioner understands this skilled nursing care is covered under which part of Medicare?

Medicare part A Medicare is federal health insurance for patients 65 years and older. It is also available to patients younger than 65 years with certain diagnoses, such as end-stage kidney disease, or disabilities. Skilled nursing facility care is covered by Medicare Part A .A consecutive 3-day inpatient hospitalization within the last 30 days is typically required by Medicare to qualify for skilled nursing facility care. Skilled nursing facilities provide 24-hour nursing care services, such as medication administration and wound care. Skilled nursing facilities also offer supervised rehabilitation with occupational therapists, physical therapists, and speech-language pathologists. In addition to skilled nursing facility care, Medicare Part A helps cover home health services, inpatient care, and hospice care.

A 72-year-old man was recently discharged from the hospital after undergoing a below-the-knee amputation. The hospital discharge planner ordered the patient a wheelchair to assist with his mobility. What Medicare plan would cover the cost of the wheelchair?

Medicare part B Medicare is a government-based health insurance program that United States citizens are eligible to receive upon their 65th birthday. Medicare health insurance is divided into separate categories that are responsible for paying for various health care-related expenses. Medicare part B (B) is the health insurance that covers outpatient care and certain medical services and durable medical equipment. For example, wheelchairs, oxygen, and ostomy supplies are considered durable medical equipment

A 70-year-old woman presents to the clinic today to discuss concerns with her vision. She states that she may need a prescription for glasses as she feels her vision has been worsening. She is worried about how to pay for new glasses. Which Medicare plan would cover this patient's glasses?

Medicare part C Sometimes called Medicare Advantage Plan, provides supplemental coverage for items such as dental and vision needs.

Minors do not need parental consent for?

Minors do not need parental consent for care regarding pregnancy, contraception, or sexually transmitted infections. Additionally, minors who are active duty military or legally married are considered emancipated and thus would not need parental consent.

A 78-year-old man presents to the clinic with his son. His son reports that the patient has had several episodes of intermittent confusion over the past few months. Which diagnostic tool could aid in the diagnosis of dementia?

Montreal Cognitive Assessment Functional assessment should be routinely performed during office visits with older patients. One of the key components of functional assessment is screening for memory disturbances. There are multiple scales that can be used, including the clock-drawing test, the Mini-Cog test, and the Montreal Cognitive Assessment.Cognitive function assessment is important for older patients. Despite advances in medical imaging, there is still no direct testing available to analyze cognition, which necessitates the continued use of both brief and prolonged mental status scales. The Montreal Cognitive Assessment (MoCA) is one of the most commonly used scales. It is graded on a 30-point scale, and focus areas include word recall, executive function (including clock drawing), language, attention, and orientation. The advantage of the MoCA over other mental status tests is that it is more sensitive to picking up cognitive decline in early stages.

An 89-year-old patient with a history of Alzheimer disease presents to the clinic for his annual physical exam. He reports that he is not currently taking his medications, as his primary caregiver has knowingly not picked them up from the pharmacy in a few months. Which of the following terms does this represent?

Neglect Elder abuse is defined as an act, or lack of action, that causes harm to an older adult. It is caused by a trusted person with an established responsibility for the older adult, such as a family member or caregiver. Neglect is a type of elder abuse and is characterized as a lack of response to an older adult's needs. This may include withholding access to medications or care.

A patient has an established diagnosis of gastroesophageal reflux disease (GERD) and is responding well to his proton pump inhibitor (PPI). The nurse practitioner decides that an esophagogastroduodenoscopy (EGD) study is not necessary. The nurse practitioner's decision exemplifies which of the following ethical principles?

Nonmaleficence Modern-day ethics is an important aspect of health care decision-making. Nonmaleficence is the commitment to not harm patients and is based on the Latin phrase that translates to "first, do no harm." In this scenario, the patient's GERD is responding well to the PPI. EGD is an invasive diagnostic procedure that could potentially cause harm to the patient. Since the patient is responding well to the treatment, there is no need to perform this invasive procedure. Additionally, the patient's treatment plan most likely would not change.

A 73-year-old man presents for follow-up of a recently treated pneumonia. He has completed his entire course of antibiotics but notes that his shortness of breath has worsened, and he now has a cough that is productive of blood-tinged sputum. His vital signs are within normal limits in the office today. What would be the most appropriate next step in management?

Obtaining a repeat chest X-ray. This patient is presenting with worsening pulmonary symptoms despite adequate treatment for pneumonia. Additionally, he is presenting with new hemoptysis. Both are concerning for potential alternative diagnoses other than pneumonia. The best first step in continuing his workup would be obtaining a repeat chest X-ray .Pneumonia is a frequently diagnosed and treated infection in the primary care setting. It is classically diagnosed via chest radiography, often a chest X-ray. Typical chest X-ray findings in pneumonia can range from single lobe dense consolidation to multilobar patch infiltrates. Pulmonary symptoms will often improve in most cases of bacterial pneumonia within the first few days of initiating antibiotics. In patients with improving symptoms, repeat imaging is often not necessary. However, in those with unimproved or worsening symptoms, repeat imaging should be done to exclude alternative causes. An alternative cause that is always of concern is lung carcinomas. Initial consolidative changes from pneumonia may mask underlying nodules on chest X-rays that could indicate a potential malignancy. In patients with worsening symptoms, repeat imaging can always be started by obtaining a chest X-ray. If chest X-ray findings are unequivocal, the nurse practitioner can consider advanced imaging with a CT scan, as this is more specific for finding nodules and other metastatic changes.

Which of the following correctly identifies an aspect of the implementation of Health Information Technology for Economic and Clinical Health Act of 2009?

One of the core "meaningful use" measures enacted by the Health Information Technology for Economic and Clinical Health (HITECH) Act was the recording of smoking status in those who are 13 years of age and older Meaningful use reporting aids in tracking legal compliance and provides the government with data to adjust reimbursement rates to nurse practitioners via public insurance (Medicare and Medicaid).Meaningful use is a set of data-driven measures implemented by the HITECH Act to prove the integration of electronic health records into practices, rewarding early adopters and penalizing practices that do not meet minimum standards.

Which religious group observes the Sabbath from Friday at sundown to Saturday at sundown?

Orthodox Jews

A 68-year-old man presents to the clinic with a new urinary concern. Which of the following symptoms would warrant a referral to urology?

Painless hematuria Painless hematuria is a sign of bladder cancer, especially in older male patients. A patient with this symptom should be referred to urology. Additionally, a urine sample should be sent for both culture and cytology. As the risk of kidney and bladder lesions increase with age, even a single positive urinalysis for microhematuria without injury or pain should be fully evaluated. If there is no obvious benign diagnosis (trauma, menstruation, infection), a referral to urology is warranted.

What is the goal of the Transitional Care Model?

Prevent hospital readmissions and illness exacerbations Patient well-being is at the center of the Transitional Care Model. The model goal focuses on continuity of care to prevent hospital readmissions and illness exacerbations. Timely and thorough information sharing via extensive case management and thoughtful discharge planning support meeting the model goal.

The nurse practitioner recommends that a patient with an increased atherosclerotic cardiovascular disease risk score take a low-dose aspirin daily. Which level of prevention is this?

Primary prevention In health promotion, there are three levels of prevention. The first level is primary prevention, which focuses on the prevention of disease. Modern medicine has shifted heavily toward the use of primary prevention. Common examples of primary prevention include vaccinations, nutrition and exercise counseling, smoking cessation, and stress reduction. Secondary prevention involves screening for diseases, for example, a screening colonoscopy for colon cancer. The final level of prevention is tertiary prevention, which is the treatment of a diagnosed illness to prevent further disease sequelae.

An 82-year-old man with multiple comorbidities presents to the clinic with difficulty urinating. During the digital rectal exam, several hard nodules are felt on the prostate, and it is noted to be edematous. Which of the following diagnostic tests would confirm the suspected diagnosis?

Prostate Biopsy A biopsy of the prostate is the confirmatory test for suspected prostate cancer. Patients with abnormal digital rectal examinations should be referred for urologic evaluations, as this can be a manifestation of prostate cancer. The decision to proceed with a biopsy should be made in conjunction with the patient and their goals of care. For patients who have a life expectancy of < 10 years from diagnosis or significant comorbidities, goals of care may better align with less aggressive diagnostics and interventions to improve quality of life.

A 94-year-old man and his son present to the clinic today for the patient's annual checkup. The patient has recently been diagnosed with early-stage prostate cancer, and his son is upset because the oncologist refused to initiate treatment. Which of the following is the best response from the nurse practitioner?

Prostate cancer grows slowly, and the side effects of treatment are likely to outweigh the benefit in this scenario

A 14-year-old girl presents to the clinic today by herself, stating that she is not sure what to do because she was just sexually assaulted by a family member. Which of the following actions should the nurse practitioner prioritize before completing a thorough interview?

Reassuring the patient that they are safe is integral to facilitating a nonjudgmental interview with open dialogue

Which of the following situations requires informed patient consent prior to the sharing of protected health information?

Reporting protected health information (PHI) for a clinical study will always require informed consent from the patient. While many scientists deidentify the information and aggregate it for further analysis within their studies, patients must agree to have their PHI released before it is used. Informed consent, in this case, provides the patient details of what information will be collected, how it will be used, how it may be aggregated or deidentified, and where and how long it will be kept.The primary law governing the use of PHI and the safety regarding it is the Health Insurance Portability and Accountability Act (HIPAA), which also details penalties to the breaching agency and requires reporting to the patient if PHI is misused. Patient information safety is a serious concern. The law requires documented informed consent prior to releasing information via other methods.

A pregnant patient and her partner present to the clinic for a new obstetric visit at 10 weeks gestation. They report that their culture is adamantly against any internal vaginal exams during pregnancy. After educating them on vaginal exams in pregnancy, the nurse practitioner communicates that it is an acceptable decision to decline the exam at this visit. Which of the following patient-centered care principles is the nurse practitioner demonstrating?

Respect for the patient's values and preferences Helps involve the patient in shared decision-making and shows them that the nurse practitioner recognizes them as a unique individual. When a patient is given information to make an informed decision, it is acceptable for them to choose their management plan, even if the nurse practitioner disagrees. Culture affects how patients understand medical care and how that care will impact their lives. Not all patients want to be part of clinical decision-making, but most patients want accurate, honest information that is focused on their values and preferences. The nurse practitioner can use education, communication, and shared decision-making to clarify options and develop a mutually agreed-upon plan of care that is culturally appropriate.

A 36-year-old woman presents to the clinic for a 28-week obstetrical visit. She reports she has a stressful job and having a glass of wine most weeknights is the only thing that helps her relax. The nurse practitioner responds, "Thank you for sharing that with me. Let's talk about things you can do to relax without alcohol." The nurse practitioner's response uses which principle of motivational interviewing?

Self-efficacy is the belief that one can accomplish a specific task. Improving self-efficacy requires eliciting and supporting hope, optimism, and the feasibility of accomplishing change. A nurse practitioner using motivational interviewing may support self-efficacy by reflecting it and then asking a key question. This nurse practitioner supported the patient's self-efficacy by helping her recognize one of her personal strengths and asking her a key question about other resources available.

A 63-year-old man diagnosed with chronic obstructive pulmonary disease (COPD) has a COPD Assessment Test score of 6. He has not had any severe exacerbations or hospitalizations in the last year, placing him in treatment Group A. Which medication is the best initial treatment?

The Global Obstructive Lung Disease (GOLD) guidelines recommend short-acting or long-acting bronchodilators as initial therapy for COPD treatment Group A. Therefore, levalbuterol (Xopenex), a short-acting beta-agonist (SABA), is an appropriate medication. Long-acting beta-agonists (LABA) can also be considered.

A 60-year-old man presents to the clinic for a follow-up on diabetes. He has an HbA1C of 8.7% at today's visit, an increase from 7.9% 3 months ago. After educating him that he will likely need to start insulin soon, the patient decides to commit to eating a healthy diet and starting an exercise routine. Which model best exemplifies the patient's perception and potential behavior change?

The Health Belief Model The Health Belief Model states that people will take positive health actions to prevent negative health outcomes. To prevent being placed on insulin, the patient is taking positive actions, such as increasing his diet and exercise.

An 89-year-old patient presents to the office today with his daughter. She states that he has appeared more forgetful and more confused over the past 4 days, which has led to increased agitation. Which of the following would be the most appropriate next step?

The Mini-Mental State Exam (MMSE) Confusion in older patients should prompt the nurse practitioner to further investigate both neurologic and non-neurologic causes. The Mini-Mental State Exam (MMSE) will help confirm whether or not cognitive deficits exist. The MMSE is a set of 11 tests over the course of 5-10 minutes that reliably identify cognitive impairment, with the limitation of not eliciting a cause or etiology. The Confusion Assessment Method diagnostic algorithm may also be useful in differentiating delirium from confusion. Further assessments of pain scale, evaluation for fever, history of recent medication or alcohol use, and questioning the presence of constipation are all helpful in uncovering the underlying source of the patient's altered mental state. Consideration should be given to ordering a urinalysis, as a urinary tract infection is a common cause of confusion in older patients.

A primary care nurse practitioner strives daily to provide patients with the best care according to the most up-to-date clinical practice guidelines. Which of the following is an attribute of a good practice guideline?

The best guidelines are those based on systematic reviews of the most current evidence and patient-oriented evidence, exhibiting a transparent development process and using a clear evidence-rating system.

After the death of her mother, a young adolescent begins fulfilling previous duties held by her mother, including cooking meals and ensuring her siblings complete their school work. This is an example of which of the following?

The family systems theory

A 69-year-old man presents to the office today with his wife. His wife states that over the last 6 months, she has noticed that he takes several naps each day, walks more slowly than he used to, constantly itches his scalp, and has had mild difficulty completing his day-to-day tasks. She also expresses concerns that his hands are always moving, even if he is not doing anything. With his worsening symptoms, the patient appears withdrawn, sad, and less interested in his usual activities. What should the nurse practitioner tell the patient about his diagnosis and the related cause?

The most likely diagnosis for this patient is Parkinson disease. Parkinson disease is a neurodegenerative disease caused by the loss of dopaminergic neurons in the brain

A clinician calls a nurse practitioner at a different practice inquiring about the treatment plan for their close friend. Which of the following statements is correct in regard to this situation?

The nurse practitioner cannot share information as HIPAA sets boundaries on the use and release of protected health information (PHI), giving more control to the patient Information release is limited to the minimum reasonably needed for providing health care. Exceptions to this rule are sharing information with the patient's insurance company, reporting abuse, or consulting with other clinicians. It would be inappropriate to share a patient's health information with a friend without the patient's consent.

A test result confirms that an 18-year-old patient is positive for a sexually transmitted infection. Which of the following confirmed infections should the nurse practitioner report to the local health department for CDC notification?

The nurse practitioner should report confirmed Chlamydia trachomatis infection to the local health department for CDC notification Chlamydia is on the CDC National Notifiable Diseases Surveillance System (NNDSS) list of nationally notifiable infectious diseases. The NNDSS is used by all US states and territories to monitor, control, and prevent the spread of around 120 diseases and conditions. Although the notifiable diseases list is considered voluntary, it is the responsibility of the nurse practitioner to report cases of these diseases to their local health department. Notifiable disease data is deidentified and sent from the local health department to the CDC to monitor diseases at a national level.There are currently seven sexually transmitted infections (STIs) on the NNDSS list: chlamydia, chancroid, gonorrhea, hepatitis B virus, hepatitis C virus, HIV, and syphilis. Other common conditions on the NNDSS list include certain foodborne illnesses (such as gastrointestinal infection caused by E. coli) and respiratory infections (such as COVID-19). While notifiable diseases are voluntary to report, each local or state health department also has a list of mandatory reportable diseases. Diseases may appear on both the reportable diseases list and the CDC notifiable diseases list. It is the responsibility of the nurse practitioner to be familiar with the list of mandatory reportable diseases in their respective location. Local health departments use case information regarding reportable diseases to obtain further information about affected patients, investigate the illness, and prevent further spread.

A new nurse practitioner applies for eligibility to bill Medicaid for his services. He understands that which of the following is the correct description of Medicaid?

The nurse practitioner understands that Medicaid is funded at state and federal levels and provides coverage for patients with reduced incomes Medicaid is available to eligible patients with limited incomes and resources, including pregnant patients, children, patients 65 years and older, patients with blindness, and patients with disabilities.Each state sets specific requirements for Medicaid eligibility and benefits based on federal guidelines. Select Medicaid benefits are mandatory under federal law, including inpatient care, outpatient care, home health services, family planning care, and laboratory services. Benefits for patients who are pregnant include nurse midwife services and tobacco cessation counseling during pregnancy. The Early and Periodic Screening, Diagnostic, and Treatment program requires states to provide dental care for patients with Medicaid coverage until they are 21 years old.

A patient is seen in the office for a follow-up visit by the nurse practitioner. The nurse practitioner understands that to use incident-to billing, the following conditions must be met:

The patient who has Medicare and is seen for a follow-up visit for hypertension while the physician is in the office at the time of the visit In order for the nurse practitioner to use incident-to billing, several requirements must be met. As incident-to billing only applies to services billed to Medicare, the patient needs to have Medicare as their primary insurance. The patient needs to be seen in a non institutional setting, and the physician must be present in the office for the duration of the visit. The patient must be seen for an established concern for which the physician previously saw the patient and developed a plan of care. The nurse practitioner is then seeing the patient for follow-up care only. In the scenario above, the patient who has Medicare and is seen for a follow-up visit for hypertension while the physician is in the office at the time of the visit meets the necessary requirements to use incident-to billing.

A 21-year-old man patient became dependent on narcotics after sustaining injuries from a severe motor vehicle accident. He now wants to quit and is researching Narcotics Anonymous meetings in the area. This is an example of which stage of change from the Stages of Change Model?

The preparation stage of the Stages of Change The preparation stage of the Stages of Change, or the Transtheoretical Model, involves intentionally taking steps to prepare for the change. The model posits that individuals move through various stages as they cease unhealthy behaviors or adopt healthy ones. Researching Narcotics Anonymous meeting information exemplifies this stage.

A 68-year-old woman with a history of atrial fibrillation, major depressive disorder, and a cerebrovascular accident gives the nurse practitioner a list of her medications. Aside from her prescribed medications and a multivitamin, you notice that she also takes St. John's wort and ginkgo biloba daily. Which patient statement demonstrates the need for further education?

The risks of taking St. John's wort and ginkgo biloba in addition to prescription medication warrant further education St. John's wort is commonly promoted for the treatment of depression, among other conditions. Research findings support its efficacy over placebo for mild to moderate depression. Patients are often unaware of the potential dangers of herbal supplements primarily because they can be bought over the counter. This patient may have been prescribed a selective serotonin reuptake inhibitor because they are typically the first-line treatment for depression. This would warrant education to discontinue St. John's wort because the combination of serotonin in both medications can lead to serotonin syndrome. Patient presentations of serotonin syndrome are agitation, tachycardia, shivering, tremors, seizures, and potential death. Ginkgo biloba is primarily used for memory and cognition. Ginkgo is contraindicated in patients taking anticoagulants or anti-platelets because this supplement interacts with platelet conjugation, leading to an increased risk of bleeding. The patient is likely taking an anticoagulant, given her history of atrial fibrillation and cerebrovascular accident.

A 76-year-old man is diagnosed with community-acquired pneumonia for which the nurse practitioner prescribes appropriate antimicrobial therapy. When the patient is given the prescription and discharge instructions, he asks the nurse practitioner for a cough suppressant. Which of the following statements is the most appropriate response?

The use of cough suppressants may impede secretion clearance and could cause harm to patients Patients who present to outpatient clinics with an acute cough should be evaluated for pneumonia. Pneumonia is an infection within the lung parenchyma. The presence of cough plus dyspnea, pleural pain, or aches and pains are clinical symptoms of pneumonia. The presence of fever or tachypnea should raise the nurse practitioner's suspicion for pneumonia. Diagnosis is confirmed with chest radiography

An 82-year-old woman with a history of hypertension and chronic kidney disease presents to the clinic with symptoms of fatigue, dry skin, edema, and nocturia. Upon evaluation of her lab results, the nurse practitioner notes that the patient's glomerular filtration rate is 55 ml/min/1.73 m². Her glomerular filtration rate was 57 ml/min/1.73 m² three months prior. Based on this patient's stage of kidney disease, what is the priority intervention indicated for management?

This patient can be diagnosed with stage 3a chronic kidney disease (CKD) by KDIGO criteria, necessitating individualized blood pressure control, a salt-restricted diet, and a weight management The Kidney Disease: Improving Global Outcomes committee stages kidney disease based on glomerular filtration rate and albuminuria. The committee suggests that individualized blood pressure be targeted to prevent progression of kidney disease. Patients should also eat < 2 grams of salt per day. It is also recommended that patients exercise five days per week for 30 minutes.

A patient under age 18 presents to the office requesting to be seen. For which of the following scenarios would parental consent be necessary to treat the patient?

This patient will need a vaginal examination for concerns of extremely painful cramps and moderate bleeding Minors are required to have parental or legal representative consent in the case of sensitive examinations, such as a vaginal examination. Nurse practitioners must maintain respect for their patients' dignity during examinations and procedures, taking care to perform them in a professional manner. The parent's consent also decreases the risk of instances of alleged misconduct by the nurse practitioner. Respectfully and effectively providing information about a patient's medical conditions will also involve encouraging the minor patient to participate in decisions regarding their care. Many states have enacted new laws governing pelvic exams on minors.

A 64-year-old woman of Asian descent is being seen in the clinic for a post-hospitalization follow-up and medication check. The patient experienced a myocardial infarction and required stent placement and was subsequently readmitted 1 week ago for in-stent restenosis. The patient states that clopidogrel (Plavix) was discontinued during the hospitalization, and ticagrelor (Brilinta) was prescribed. She asks, "Why did this medication change happen?" Which of the following is the most appropriate response from the nurse practitioner?

Ticagrelor is an appropriate alternative P2Y₁₂ inhibitor that is associated with a slightly increased risk for thrombocytopenia but reduced mortality risk in patients of East Asian descent. P2Y₁₂ inhibitors function as antiplatelet agents. Clopidogrel is one type of P2Y₁₂ inhibitor. It is a prodrug that requires hepatic metabolism to be converted into its active metabolite. Clopidogrel is typically combined with aspirin as a part of dual antiplatelet therapy for patients following myocardial infarction and with coronary artery syndrome. However, 40% of patients do not derive benefit from treatment with clopidogrel. In addition, clopidogrel contains a boxed warning for patients who are poor metabolizers of CYP2C19, leading to a lack of drug efficacy and an increased risk of adverse cardiac events. Patients of East Asian descent have an increased likelihood of carrying a genetic variation causing poor metabolism of clopidogrel

Which of the following cultures originated the belief that an imbalance between yin and yang causes illness?

Traditional Chinese Traditional Chinese culture believes in the balance of yin and yang. It is believed when these two are off balance, illness can result. The belief in balance between hot and cold originated with traditional Chinese medicine. In this instance, hot and cold refer to qualities, not temperatures. The belief includes that when the balance between yin and yang is restored, illness can be cured. For example, an individual may consume cold foods and drinks to cure a hot illness. This belief has influenced traditional medical practices across Asia, India, and Central and South America. However, any cultural belief can be a broad generalization and should never be used to stereotype individuals.

A 93-year-old patient who has cirrhosis and is homebound is evaluated by a nurse practitioner at home. According to results from the Independence at Home Demonstration conducted by the Centers for Medicare and Medicaid Services, which of the following parameters remained unchanged with home-based primary care?

Use of skilled nursing facilities One of the largest studies of home visits is the Independence at Home Demonstration conducted by the Centers for Medicare and Medicaid Services. It is ongoing and tests the effectiveness of providing primary care services at home and if this improves chronic conditions. The study has shown a reduction in expenditures, hospitalizations, and 30-day readmission rates due to house calls. Parameters that remained unchanged include the use of skilled nursing facilities (D), inpatient rehabilitation, home health agencies, and hospice. Home-based primary care is increasingly in demand in the United States due to the growing population of older adults and patients who are homebound. The difficulties and dangers of hospital visits during the COVID-19 pandemic have brought the need for house calls into sharper focus, and Medicare and other insurance reimbursements for home visits are increasing. House calls allow the nurse practitioner to spend more time with the patient and assume higher levels of accountability for comprehensive care. Several additional studies have demonstrated the benefits of house calls, including higher-quality patient care and more efficient resource use.

A 77-year-old man presents to the office reporting feeling like a "fish is flopping" in his chest. He states he has felt more tired when he is working out and almost passed out yesterday at the gym. The nurse practitioner performs an ECG in the office that shows an irregular rhythm with no distinguishable P waves. Which of the following is the most likely diagnosis?

atrial fibrillation "Fish flopping" and exercise intolerance are classic symptoms in the presentation of atrial fibrillation, in addition to syncope and lightheadedness. The key finding on an ECG is an irregular rhythm with the absence of P waves. Atrial fibrillation results in incomplete emptying of blood from the atria to the ventricles, causing compromised cardiac output to the body. Further, blood pooling in the atria creates risk of clot formation, so patients with atrial fibrillation are at risk for thromboembolism. Management of atrial fibrillation consists of rate control with antidysrhythmics, including beta-blockers or calcium channel blockers, and anticoagulation to mitigate risk of embolic events like stroke.

At an annual visit, a 28-year-old woman tells the nurse practitioner that she knows smoking is bad for her and is considering quitting. What stage of readiness to change is she exhibiting?

contemplation In the contemplation stage, the patient recognizes a problem exists and is considering a treatment or behavior change. In this stage, the patient is receptive to advice but is not yet ready for an action program. However, the nurse practitioner can help the patient to identify barriers, address concerns, and identify support systems.

A 75-year-old man presents to the office for an annual physical. He reports seasonal allergies and mild urinary hesitancy, which are unchanged since last year. He was last seen 3 months ago for a wrist sprain, which has resolved. Which of the following diagnostic tests is customarily ordered when older patients present for annual physical examinations?

glomerular filtration rate (GFR) All of these tests may be appropriate to order for various reasons, but the most appropriate to order today would be related to the kidneys. As patients age, their glomerular filtration rate (GFR) (B) decreases and, if left unassessed over time, can lead to chronic kidney disease. Therefore, routine kidney function testing (every 1 to 2 years) is indicated in older adults. Kidney function is important to monitor in older patients, particularly those with multiple medications, as elimination time may be altered and dosing may need to be adjusted. In addition, medications that are chronically irritating to the kidneys, such as NSAIDs, may need to be limited or eliminated. GFR is the gold standard for measuring kidney function, as it is a real measure of filtration speed and efficiency within the kidneys. GFR is difficult to measure directly, requiring timed urine collection or specialty marker tests. Therefore, it is usually estimated (eGFR) through calculations such as the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation.

An 82-year-old woman presents to the office with severe pain, redness, warmth, and swelling of the distal interphalangeal joint on her right hand. She does not recall a recent injury to her hand. Which diagnosis may be responsible for her acute symptoms and should be evaluated for?

gout Based on the pain, redness, warmth, and swelling this patient is experiencing in her finger, gout should be considered. Gout, although more common in the great toes and knees, can occur in the fingers. Differential evaluation should include evaluation for systemic symptoms caused by cellulitis, such as fever, chills, nausea, and vomiting, and a history of gout flare or alteration in diet for gout. If the patient had a recent injury, like an impact or scrape to the finger, this would weigh the evaluation more heavily toward cellulitis.

Health promotion interventions:

grouped according to the three levels of prevention: primary, secondary, and tertiary. Primary prevention strategies target the prevention of illness, injury, or disability. Public campaign interventions promoting vaccinations are an example of a primary prevention strategy. Secondary prevention strategies target early detection and treatment of disease, especially for populations at increased risk. For example, annual mammograms for patients beginning at age 40 are recommended for early detection and treatment of breast cancer. Further, health outcomes are improved when cancer is detected and treated early. Tertiary level of prevention targets further exacerbations or complications in individuals that have developed the disease. For example, teaching insulin injection techniques to patients with diabetes increases the patient's self-efficacy for diabetes management and lowers the risk of hyperglycemia

A patient with private insurance presents to the nurse practitioner to get a referral to see an allergist for more in-depth allergy testing. Which of the following regarding their insurance plan is correct?

health maintenance organization (HMO) insurance This patient is likely covered under health maintenance organization (HMO) insurance, as they are required to have a gatekeeper, such as their primary care provider, and must get a referral to see a specialist. HMOs require that patients see clinicians who are in the insurance network and are typically a cheaper insurance option for the patient. Network-based insurance attempts to control health care costs by setting clinician reimbursement at a standardized level, emphasizing preventative care, and steering patients to less-expensive health care options (e.g., primary care rather than a specialist). Requiring a higher outlay of financial contribution from the patient for going out-of-network limits costs by discouraging excessive visits and outreach.

An 86-year-old woman presents to the clinic for a routine evaluation. She has completed her annual screenings without issue, and you review her most recent laboratory panel with her, which had no abnormalities. She takes all of her medications as prescribed and has no concerns at this time. You take this opportunity to discuss advance care planning. Which of the following factors is associated with an increased likelihood of advance directive completion?

provided early education material As patients reach the final decades of their lives, advance directives and surrogate decision-maker assignments can play a critical part in a patient's health care. A recent study showed that when clinicians and caregivers provided early education material regarding the completion of advance directives and identifying surrogate decision-makers, adherence to those plans went up significantly. By providing patients with access to trained facilitators and educational materials and tools that take into account their goals, preferences, and values, patients are more likely to complete an advance directive and to be prepared in the event decision-making capacity is lost. Advanced care planning should take into account the patient's preferences, goals, and values. It is the nurse practitioner's responsibility to educate the patient on treatment options and to help them explore their personal preferences through a risk-benefit analysis. Planning will help the patient and their family make the best possible decisions during in-the-moment situations with patient autonomy and quality care in place.

A 91-year-old man presents to the clinic with his caregiver requesting medication refills. The nurse practitioner suspects elder abuse when multiple bruises are noted on the upper arms and neck region. Which of the following must be included in the plan of care for this patient?

report the suspected abuse

A 60-year-old woman presents with dull, aching pain in her lower back with occasional weakness in her left foot. She states that the pain is relieved when she sits down and rests. Based on this information, which of the following conditions should the nurse practitioner prioritize on the differential diagnosis?

spinal stenosis This patient is describing symptoms most consistent with spinal stenosis. Spinal stenosis occurs as a result of narrowing in the spinal canal and is most likely to affect individuals over 50 years of age. Patients with spinal stenosis describe back pain that worsens with walking and is relieved by sitting.

A primary care practice has decided to implement a new system for electronic medical records. The staff have decided as a whole that their charting system could be more efficient and hope to get their office manager's support for this change. Which phase of the Lewin change model does this scenario represent?

unfreezing Unfreezing occurs before the change happens and includes assessing and raising awareness of how organizational mindset, behavior, and culture are hindering progress toward needed change and getting support for that change.