AGACNP Exam Review

AGACNP Exam Review Scope of Practice - ANS-Based on legal allowances in each state, individual state nurse practice acts providing guidelines for nursing practice Key elements of the NP role include - ANS-integration of care across the acute illness continuum with collaboration and coordination of care; research based clinical practices, clinical leadership, family assessment, and discharge planning Standards of Advanced Practice are delineated by... - ANS-American Nurses Association which measure quality of practice, service, or education State Practice Acts - ANS-Authorize Boards of Nursing in each state to establish statutory authority for licensure of RNs State Practice Acts - authority includes: - ANS-use of title, authorization for scope of practice including prescriptive authority, and disciplinary grounds States vary in practice requirements, such as - ANS-certification Prescriptive authority - ANS-Ability and extent of NPs ability to prescribe meds DEA has ruled that nurses in advanced practice may obtain.. - ANS-registration numbers, state practice acts dictate level of prescriptive authority allowed Credentials encompass... - ANS-required education, licensure and certification to practice as an NP Credentials establish... - ANS-minimal levels of acceptable performance Credentialing is necessary to: - ANS-ensure that safe healthcare is provided by qualified individuals; comply with federal and state laws r/t APN Credentials also... - ANS-acknowledges the scope of practice of NP, mandates accountability, enforces professional standards for practice Licensure - ANS-establishes that a person is qualified to perform in a particular professional role Licensure is granted as defined by rules and regulations set forth by - ANS-a governmental regulatory body (ie. state board of nursing) Certification - ANS-Person has met certain standards that signify mastery of specialized knowledge Certification is granted by nongovernmental agencies such as - ANS-ANCC, AANP Admitting privileges to hospitals (non physican) were granted - ANS-1983 by JC Credentialing and privileging - ANS-process which an NP is granted permission to practice in an inpt setting Credentialing with hospital privileges is granted by a - ANS-Hospital Credentialing Committee Pt Medical Abandoment - ANS-When caregiver-pt relationship is terminated w/o making reasonable arrangements w an appropriate person so that care can be continued Determination of pt abandonment depends on factors such as: - ANS-Whether NP accepted pt assignment, whether NP provided reasonable notice before termination, whether reasonable arrangements could have been made Following do not constitute pt abandonment - ANS-NP refuses to accept responsibility for pt assignment when NP has given reasonable notice to proper authority that NP lacks competence to carry out assignment; NP refuses assignment of a double shift or addtl hrs beyond posted work schedule when proper notification has been given..latter phrase can be controversial Risk Mgmt - ANS-Systematic effort to reduce risk begins w formal written risk mgmt plan that includes: organizations goals, delineation of program's scope, components, methods; delegating responsibility for implementation and enforcement; demonstrating commitment by the board; confidentiality and immunity from retaliation for those who report sensitive info Most common method of documentation for risk mgmt - ANS-incident reports Policies regarding incident reports should address: - ANS-ppl authorized to complete report; ppl responsible for review of a report, immediate actions needed to minimize the effects of the event; ppl responsible for follow up; plan for monitoring aftermath; security/storage of completed report Risk mgmt - Satisfaction surveys - ANS-Important for identifying problems before they develop into incidents or claims; for pts and employees Risk mgmt - Complaints: Risk mgmt plan should delineate tracking, analyzing, and managing complaints by clearly identifying: - ANS-ppl notified after receiving complaint; ppl responsible for responding; ppl responsible for monitoring follow up Action taking initiatives: - ANS-Prevention, correction (corrective steps must be monitored and audited), documentation, education, departmental coordination Medical Futility - ANS-Interventions that are unlikely to produce significant benefit for pt - "Does the intervention have any reasonable prospect of helping this pt?" Two kind of medical futility: - ANS-Quantitative futility: likelihood that intervention will benefit pt is extremely poor Qualitative futility: quality of benefit an intervention will produce is extremely poor Informed consent - competence (decisional capability) - ANS-state that pt is able to make personal decisions about their care competence implies that ability to: - ANS-understand, reason, differentiate good and bad, and communicate informed consent - ANS-pt has received adequate instruction or info regarding aspects of care to make prudent, personal choice regarding such tx Informed consent includes: - ANS-discussing benefits and risk consent is assumed if... - ANS-pt's condition is life threatening Danforth Amendment 1991 - ANS-pts are informed at time of admission to federally funded institution (such as hospital, nursing home, hospice, HMO, etc) that they have the right to refuse care as long as the pt has decisional capability (competence) Ethics - ANS-study of moral conduct and behavior protecting the rights of an individual 1st priority is the - ANS-most salvagable pts. Most critically injured cared for last. Key ethical principles are: - ANS-nonmaleficence, utilitarianism, beneficence, justice, fidelity, veracity, autonomy Nonmaleficence - ANS-duty to do no harm Utilitarianism - ANS-the right act is the one that produces the greatest good for the greatest number Beneficence - ANS-duty to prevent harm and promote good Justice - ANS-duty to be fair Fidelity - ANS-duty to be faithful Veracity - ANS-duty to be truthful (tends to be in conflict with fidelity) Autonomy - ANS-duty to respect an individual's thoughts and actions (tend to be in conflict with beneficence) Dismissing/discharging a pt or closing practice - ANS-NP cannot withdraw from caring for a pt without notification Examples of reasons for discharging a pt from practice: - ANS-abuse, refusal to pay, persistent non-adherence to care Steps for discharging a pt from practice: - ANS-send a certified letter with return receipt (copy for chart), provide general healthcare coverage for 1st 15-30 days post termination deadline, obtain release of info to provide copies of all needed records for next care provider Obligations in closing practice d/t relocation, retirement - ANS-give pt adequate time to find another provider, keep all files for min 5 years, provide timely notification and names of other providers and resources for future care Role of NP developed in the early... - ANS-1960s as a result of physician shortages in the area of peds First NP program was peds, begun in... - ANS-1964 by Dr. Loretta Ford and Dr. Henry Silver at CU Health Sciences mainly focusing on ambulatory and outpt care Historical service of NPs in primary care resulted in part from the... - ANS-availability of federal funding for preventive and primary care NP education Movement of NPs expanded to the... - ANS-inpt setting as a result of managed care, hospital restructuring, and decreases in medical residency programs 4 distinct roles for NPs: - ANS-clinician, consultant/collaborator, educator, researcher Crisis/Acute Grief Communication - ANS-Acknowledge feelings Offer self Crisis Intervention - ANS-Boundaries Security if necessary, NOT police Establish trust/rapport Advance Directive - ANS-Written statement of patient's intent regarding medical treatment The Patient Self-Determination Act of 1990 - ANS-All patients in a hospital setting are required to be advised of their right to execute an advance directive Living Will - ANS-Compilation of statements that specify which life-prolonging measures one does and does not want if they become incapacitated Durable Power of Attourney - ANS-Individual designated in the living will that is authorized to make medical decisions in the event patient is incapacitated Title I of HIPPA - ANS-Protects health insurance coverage for workers and their families in the event they change or lose their jobs COBRA COBRA - ANS-protects health insurance coverage for workers and their families in the event worker loses or changes jobs Who enforces HIPPA - ANS-Office for Civil Rights Patient Safety Rule - ANS-Protects patient information to analyze patient safety events and improve True or False: A patient has the right to see their medical record - ANS-True The Privacy Rule: Patient's Rights - ANS-See/have their medical record Corrections added to medical record Patient Safety and Quality Improvement Act (PSQIA) - ANS-Voluntary reporting system improve patient safety outcomes through anonymous reporting by providers of patient safety outcomes and events Duty to Warn - ANS-Patient's condition may endanger others overrides confidentiality Patient is diagnosed with HIV. Duty to Warn applies how? - ANS-Can notify providers not family Invasion of Privacy - ANS-Damaging one's reputation as a result of sharing patient information without their permission When can invasion of privacy charge not be made - ANS-in good faith accurate information receiver has valid reason to obtain information Initiating any change in heathcare - ANS-Begin at most local level and expand outward What comes first when treating a patient with a medical and psychosocial condition - ANS-Medical condition strongest method to evaluate teaching - ANS-returned demonstration when to transfer to teritary care facility - ANS-seriously ill or injured patients that cannot be cared for at your institution stabilize and ship Patient reluctant to undergo procedure. you should? - ANS-Fully educate patient and tell them why Primary care screening exams that are not emergent - ANS-do not delay hospital discharge refer to PCP most powerful data collected from patient - ANS-subjective or data you observed as the np RN calls you as the night shift NP and states patient is decompensating. You would? - ANS-Call primary MD when patient status changes Code goes bad and all involved are talking badly about it on the unit. You should? - ANS-Hold a one time debriefing with everyone invovled What is a response that would suggest admitting a patient to a SNF would be the best action? - ANS-Needing assistance with ADLs Goals of Healthy People 2020 - ANS-increase the quality and years of healthy life eliminate health disparities among americans Healthy People 2020 purpose - ANS-used to understand health status of the nation and plan prevention programs NP must notify department of health with what dx - ANS-Gonorrhea Chlamydia Syphillis HIV TB NPs must report to state - ANS-Criminal acts and injury from dangerous weapon (GSW) Gonorrhea Chlamydia Syphillis HIV TB Animal bites Suspected/actual child abuse Domestic violence Physical Therapy - ANS-Strength training coordination Occupational Therapy - ANS-ADLs Medicare - ANS-Third party payers sets the standard for reimbursement and cutting costs >65 yo. Disabled Medicaid - ANS-Third party payers Poverty Medicare A - ANS-Covers inpatient hospitalizations SNF home health hospice >65 yo. Medicare B - ANS-Covers physician services outpatient hospital services labs/diagnostic procedures medical equipment Pay premium NPs 85% physician scheduled fee Medicare B pays how much of bill - ANS-Medicare pays 80% and patient pays 20% Medicare D - ANS-Limited prescription drug coverage Monthly premium required Co-pay on each prescription required Incident-to-Billing - ANS-Services billed under MD provider number to get the full physician fee Under MD direct supervision Does direct supervision require MD to be physically in the room with NP to be eligible for incident-to-billing - ANS-no same office suite and easily accesible does incident-to-billing apply to the inpatient hospital setting - ANS-No. NP must bill under their NPI in the hospital setting Root Cause Analysis - ANS-Tool for identifying prevention strategies to ensure safety Culture of safety and not culture of blame Root Cause Analysis involves - ANS-Interdisciplinary experts those who are most familiar with the situation continually asking why at each level of cause and effect Identifying changes Impartial process Debriefing after an event is an example of - ANS-root cause analysis Sentinel Events - ANS-Unexpected occurrences involving death or serious physical injury or psychological injury or risk thereof immediate investigation and response Sentinel Event and medical error - ANS-not synonymous not all sentinel events occur because of an error not all medical errors result in a sentinel event Response to Sentinel Event - ANS-Root Cause Analysis Scope of Practice - ANS-Based on legal allowances in each STATE Provides guidelines for nursing practice How can the ACNP demonstrate and advocate for full scope of practice? - ANS-ACNP bills independently State Practice Acts - ANS-STATE Board of Nursing grants authority includes title, authorization of scope including prescriptive authority, disciplinary grounds What dictates the nurse practitioners prescriptive authority - ANS-State Nurse Practice Acts State Board of Nursing Credentials - ANS-Encompass required education, licensure and certification to practice as an NP Establish MINIMAL levels of acceptable performance Licensure - ANS-GOVERNMENT STATE BOARD OF NURSING Establishes a person is qualified to perform Certification - ANS-NONGOVERNMENTAL AGENCIES ANCC Establishes a person has met certain standards which signify mastery of specialized knowledge and skills Licensure vs. Certification - ANS-Government state board of nursing vs. nongovernmental agencies ancc Credentialing and Privileging - ANS-Process by which a nurse practitioner is granted permission to practice in an inpatient setting Hospital Credentialing Committee - ANS-Comprised of physcians Credentialing with hospital privileges grant Most common method of documentation in Risk Management - ANS-Incident Reports Medical Futility - ANS-Interventions that are unlikely to produce any significant benefit for the patient Quantitative Futility - ANS-Where the likelihood that an intervention will benefit the patient is extremely poor Qualitative Futility - ANS-Where the quality of the benefit an intervention will produce is extremely poor Competence - ANS-Decisional capability State in which patient can make personal decisions about their care Informed Consent - ANS-Patient has received adequate instruction or information regarding aspects of care to make a personal choice Informed Consent includes - ANS-discussing all risks and benefits Ethics - ANS-The study of moral conduct and behavior Nonmaleficence - ANS-Duty to do no harm Utilitarianism - ANS-Produce the greatest good for the greatest number Beneficence - ANS-Prevent harm and promote good Justice - ANS-To be fair Fidelity - ANS-to be faihtful Veracity - ANS-to be truthful autonomy - ANS-Respect an individuals thoughts and actions Duration of time to keep medical records after closing a practice - ANS-Minimum five years Reasoning for movement of NPs into inpatient setting - ANS-Managed care Hospital restructuring Decreases in medical residency programs Four Roles of NPs - ANS-Clinician Consultant/collaborator Educator Researcher Nonexperimental Research - ANS-No experiment design Descriptive research - ANS-Describe situations, experiences, and phenomena as they exist Ex Post Facto/Correlational Research - ANS-Examines relationships among varables Cross sectional research - ANS-Population with a very similar attribute but differ in one specific variable Relationships between variables at specific point in time Cohort - ANS-Compares one outcome in groups of individuals who are alike but differ in one characterisitc Longitudinal study - ANS-Multiple measures of a group over an extended period of time Experimental Research Design - ANS-Manipulation of variables using randomization and control groups to test the effects of an intervention or experiement Quasiexperimental Research - ANS-Manipulation of variable but lacks randomization and control group Qualitative Research - ANS-Case studies Open ended questions field study participant observations Used to explore through detailed descriptions of people, events, situations or observed behavior Drawback of qualitative research - ANS-researcher bias Level of significance - ANS-p value the probability of false rejection of the null hypothesis in a statistical test p value - ANS-level of significance t value - ANS-the mean of two groups Reliability - ANS-Degree to which an instrument measures the same way over time p <.05 - ANS-experimental and control groups are considered to be significantly different Validity - ANS-Degree to which a variable measures what it is intended to measure ANCC is creating questions for boards and is trying to make sure that these questions they are asking are correctly for ACNP's. Is this reliability or validity? - ANS-Validity. The degree to which a variable measures what it is intended to measure Liability - ANS-Legal responsibility that a nurse practitioner has for actions that fail to meet the standard of care Standards of care - ANS-criteria to measure whether negligence has occured Negligence - ANS-Failure of an individual to do what a REASONABLE person would do resulting in injury to the patient NP fails to do an EKG on a patient presenting with chest pain. This is an example of - ANS-negligence Malpractice - ANS-Failure to render services with the degree of care, diligence and precaution that another member of the same profession under same circumstances would do to prevent injury to patient Malpractice involves - ANS-professional misconduct unreasonable lack of skill illegal/immoral conduct Assault - ANS-threatening gesture Shaking a fist at someone or making the motion of injecting someone against their will is an example of - ANS-assault Battery - ANS-Violent contact Striking a person, pulling on clothes or anything in which they have contact is an example of - ANS-battery can someone commit assault on an unconscious person - ANS-no Defamiation - ANS-Communication that causes someone to suffer a damaged reputation Libel - ANS-defaming through written material Slander - ANS-spoken defamiation Can NPs order restraints? - ANS-Yes. Document why restraints are being ordered Degree to which an instrument works the same way over time - ANS-reliability How is an advanced directive different from a living will? - ANS-Advance directive a component of a living will Living will designates power of attourney Can you tell the wife the husband has HIV - ANS-no you have to say "if you were her, wouldnt you want to know" ICU patient is improving but fails the swallow evaluation. What is your next action? - ANS-Patient does not need ICU. Transfer to sub-actue not med-surg Hispanic M does not speak english and you are evaluating pain. What do you use? - ANS-Visual pain scale 25 yo. M s/p MVC and cannot feed himself. Who do you consult? - ANS-Occupational Therapy What is the best way for a NP to get involved with policy change? - ANS-Join a hospital committee Family is struggling with their father's decompensating condition. Before you consult palliative care, you should? - ANS-Find out if the patient has an advance directive Your patient is worried about insurance coverage. What should you do? - ANS-Consult case management What is the best way to ensure better outcomes for a patient? - ANS-Get everyone under a standardized treatment plan What is the most important variable in determining significance of research before implementing the findings? - ANS-Sample size Who grants a NP permission to practice in the inpatient setting? - ANS-Hospital Credentialing Committee An ACNP notices an MCV and stops at the scene to offer assistance. Which of the following statutes protects the CNP from malpractice in this situation? - ANS-Good Samaritan statute The Federal 1999 Balanced Budget Act allowed for: - ANS-Medicare reimbursement for advanced practice nurse services The ACNP is involved in outcomes research. All of the following are examples of patient outcomes EXCEPT: a. patient satisfaction b. length of stay c. mortality statistics d. peer review - ANS-D. Peer review is not a patient outcome The nurse practitioner role in research includes: - ANS-Utilizing research findings in implementation of guidelines for patient care The Patient Self-Determination Act: - ANS-assures patient's rights to participate in and direct their healthcare decisions The ethical principle of "first do no harm" is called: - ANS-nonmaleficence 35 yo. M is admitted to the hospital with viral PNA. During his hospitalization, a HIV test is drawn and it is positive. Pt is married with two small children and states that he will not tell his wife or you have to do it. What is the most appopriate next step in the management of his care? - ANS-Explain to him the importance of informing his wife and offering support. Telling the wife would be a breach of confidentiality. The Medicare program is administered by the: - ANS-Health Care Financing Agency A healthcare plan in which nurse practitioners and MDs are employed directly by the health plan is: - ANS-a staff-model health maintenance organization (HMO) Which of the following services are reimbursed by Medicare: a. home health aids b. physical therapy c. skilled nursing services d. all of the above - ANS-D. all of the above Health Maintenance Organizations (HMOs): - ANS-provide both inpatient and outpatient services through a referral system The most common mental illness in young adults: - ANS-schizophrenia Acute Pain - ANS-Pain caused by tissue damage, usually < 6 months Chronic Pain - ANS-Continual or episodic pain of longer duration (> 6 months); combination therapy usually needed Cutaneous Pain - ANS-Localized on skin or surface of body. Herpes or sunburn. Visceral Pain - ANS-Poorly localized such as with internal organs. Gallbladder. Somatic Pain - ANS-Non localized; originates in muscle, bone, nerves, blood vessels and supporting tissue. Neuropathic Pain - ANS-Frequently caused by a tumor; involves nerve pathway injury or compression. Sciatica Step 1 of WHO's Ladder of Pain Management - ANS--ASA -APAP -NSAIDS +/- adjuvants Step 2 of WHO's Ladder of Pain Management - ANS--APAP or ASA -Codeine -Hydrocodone -Oxycodone -Dihidrocodeine -Tramadol (not available with APAP or ASA) +/- Adjuvants Step 3 of WHO's Ladder of Pain Management - ANS--Morphine -Dilaudid -Methadone -Levorphanol -Fentanyl -Oxycodone +- nonopioid analgesics +- Adjuvants Recommendation for breakthrough cancer pain - ANS-Fentanyl patches for sustained release Normal body temperature in C - ANS-37 101.5 degrees F - ANS-38.6 degrees C Causes of Fever - ANS--Bacterial, viral, rickettsial, fungal or parasitic infection -Autoimmune disease (SLE, arteritis) -CNS disease (cerebral hemorrhage, brain tumor, MS) interference with thermoregulatory process rather than fever - Malignant neoplastic disease (primary liver metastasis of cancer) -Hematologic disease (lymphoma/leukemia) - CV disease (MI, phlebitis, PE) - GI disease (IBD, alcoholic hepatitis) - Endocrine disease (hyperthyroidism, pheochromocytoma) -Misc causes (Familial Mediterranean fever, hematoma) - Neuroleptic malignant syndrome-->caused by antipsychotics causing a serotonin like response Treatment of Fever - ANS--Antimicrobials only when microbe is present -Antipyretics -Treat underlying condition NON INFECTIOUS causes of post-operative fever - ANS-1. Atelectasis 2. Increased basal metabolic rate 3. Dehydration (can spike temp) 4. Drug reactions: -Amphotericin B -TMP-SMZ - often persistent, not a spike -Beta Lactams -Antibiotics -Procainamide -Isonazid -Alpha Methyldopa -Quinidine INFECTIOUS causes of post-operative fever - ANS-1. Usually w/ subjective complaints, WBC elevation and left shift (bandemia) 2. WBC > 30,000 not usually from infection 3. Surgical incisions 4. IV sites 5. Point of entry for any catheter: culture? 6. UTI 7. Lungs 8. Sinusitis 9. Abscess (ie: intra-abdominal) Initial Treatment of Post-Operative Fever - ANS-In the absence of infection-first step is hydration and lung expansion Treatment of Infectious Post-Op Fever - ANS-1. Supportive therapy and APAP 2. Treat the apparent underlying source 3. Gram stain and C&S all invasive lines or catheters, as indicated Differential Value Indicative of Allergic Reaction - ANS-Increased eosinophil count Components of Headache Evaluation - ANS-1. Chronology **most important** 2. Location, duration and quality should also be evaluated 3. Associated activity: exercise, sleep, tension, relaxation 4. Timing of menstrual cycle 5. Presence of associated symptoms 6. Presence of "triggers" Most common type of headache - ANS-Tension Headache Tension Headache Signs and Symptoms - ANS-1. Vise-like or tight in quality 2. Usually generalized 3. May be most intense around the back of the head 4. No associated focal or neurological symptoms 5. Usually lasts for several hours Tension Headache | Management - ANS-1. OTC analgesics 2. Relaxation Migraine Headaches - ANS-Dilation and excessive pulsation of the branches of the external carotid artery, usually lasting 2-72 hours along the Trigeminal nerve pathway Migraine Headaches | Classifications - ANS-1. Migraine with aura "classic" 2. Migraine without aura "common" Migraine Headaches | Causes/Incidence - ANS-1. Onset is usually in adolescence or early adult years 2. Often + family history 3. Females > Males 4. A variety of triggers 5. Nitrate containing foods 6. Changes in the weather Migraine Headaches | Triggers - ANS-- Emotional/Physical stress - Lack or excess of sleep - Missed meals - Specific Foods (Nitrate containing, wines, cheeses...) - ETOH - Menstruation - oral contraceptives Migraine Headaches | Symptoms - ANS-- Unilateral, lateralized throbbing headache occurring episodically - Dull or throbbing - Build up gradually and last for several hours or longer - Focal neurologic disturbances may precede or accompany migraines - Visual disturbances occur commonly: visual field changes, luminous visual hallucinations - Aphasia, numbness, tingling, clumsiness or weakness may occur - Nausea and vomiting - Photophobia and phonophobia Migraine Headaches | Physical Exam Findings - ANS-- Often normal with the exception of neuro deficits - Appears Ill - Careful neuro exam for focal deficits or findings supportive of tumor Migraine Headaches | Laboratory & Diagnostics - ANS-1. Baseline studies important to rule out other organic causes 2. Blood chemistries, BMP 3. CBC 4. VDRL (Syphilis Exam) 5. Head CT 6. Other studies indicated by physical exam or history Migraine Headaches | Management - ANS-1. Avoid triggers 2. Relaxation/Stress management 3. Prophylactic Daily Therapy - Amitryptaline - Divalproex - Propanolol - Imipramine - Clonidine - Verapamil - Topiramate - Gabapentin - Methysergide - Magnesium Migraine Headaches | Management of Acute Attack - ANS-1. Rest in dark, quiet room 2. Simple analgesics, ASA taken immediately to provide relief 3. Sumatriptan 6mg SQ at onset, may repeat in 1 hour 4. Sumatriptan 25mg at onset of headache Cluster Headache - ANS-Very painful syndromes, mostly affecting middle aged men Cluster Headache | Causes/Incidence - ANS-1. No family history 2. Precipitated by ETOH 3. Severe, unilateral, periorbital pain occurring daily for several weeks 4. Occur at night, awakening from sleep 5. < 2 hours; pain free for months/weeks between episodes 6. Ipsilateral nasal congestion, rhinorrhea and eye redness may occur Cluster Headache | Physical Exam - ANS-May see eye redness and rhinorrhea Cluster Headache | Management - ANS-1. Treatment of individual attacks with oral drugs usually not helpful 2. Inhalation of 100% O2 may help 3. Sumatriptan 6mg SQ may be effective 4. Ergotamine tartrate aerosol inhalation may be effective Nutritional Considerations |Albumin Levels Indicative of Malnutrition and Protein Malnutrition - ANS-- < 3.5 = malnutrition - < 2.5 = edema Nutritional Considerations | Hgb levels indicative of malnutrition - ANS-- < 12 women - < 13.5 men Nutritional Considerations | Clinical Observations indicative of proper nutrition - ANS-- Hair not easily plucked - Pink mucous membranes - Clear nail beds free of ridges CONTINUES...