NURS 6531 Final, part one Study guide 2023/2024

A small, rural hospital is part of an Accountable Care Organization (ACO) and is designated as a Level 1 ACO. What is part of this designation? p. 2 a. Bonuses based on achievement of benchmarks b. Care coordination for chronic diseases c. Standards for minimum cash reserves d. Strict requirements for financial reporting ANSWERS ANS: A A Level 1 ACO has the least amount of financial risk and requirements, but receives shared savings bonuses based on achievement of benchmarks for quality measures and expenditures. Care coordination and minimum cash reserves standards are part of Level 2 ACO requirements. Level 3 ACOs have strict requirements for financial reporting. What was an important finding of the Advisory Board survey of 2014 about primary care preferences of patients? p. 2 a. Associations with area hospitals b. Costs of ambulatory care c. Ease of access to care d. The ratio of providers to patients ANSWERS ANS: C As part of the 2014 survey, the Advisory Board learned that patients desired 24/7 access to care, walk-in settings and the ability to be seen within 30 minutes, and care that is close to home. Associations with hospitals, costs of care, and the ratio of providers to patients were not part of these results. Which assessments of care providers are performed as part of the value-based purchasing (VBP) initiative? (Select all that apply.) p. 1 a. Appraising costs per case of care for Medicare patients b. Assessing patients' satisfaction with hospital care c. Evaluating available evidence to guide clinical care guidelines d. Monitoring mortality rates of all patients with pneumonia e. Requiring advanced IT standards and minimum cash reserves ANSWERS ANS: A, B, D Value-based purchasing looks at five domain areas of processes of care, including efficiency of care (cost per case), experience of care (patient satisfaction measures), and outcomes of care (mortality rates for certain conditions). Evaluation of evidence to guide clinical care is part of evidence-based practice. The requirements for IT standards and financial status are part of Accountable Care Organization standards What is the purpose of Level II research? p. 6 a. To define characteristics of interest of groups of patients b. To demonstrate the effectiveness of an intervention or treatment c. To describe relationships among characteristics or variables d. To evaluate the nature of relationships between two variables ANSWERS ANS: C Level II research is concerned with describing the relationships among characteristics or variables. Level I research is conducted to define the characteristics of groups of patients. Level II research evaluates the nature of the relationships between variables. Level IV research is conducted to demonstrate the effectiveness of interventions or treatments. Which is the most appropriate research design for a Level III research study? p. 6 a. Epidemiological studies b. Experimental design c. Qualitative studies d. Randomized clinical trials ANSWERS ANS: B The experimental design is the most appropriate design for a Level III study. Epidemiological studies are appropriate for Level II studies. Qualitative designs are useful for Level I studies. Randomized clinical trials are used for Level IV studies. What is the purpose of clinical research trials in the spectrum of translational research? p. 6 a. Adoption of interventions and clinical practices into routine clinical care b. Determination of the basis of disease and various treatment options c. Examination of safety and effectiveness of various interventions d. Exploration of fundamental mechanisms of biology, disease, or behavior ANSWERS ANS: C Clinical research trials are concerned with determining the safety and effectiveness of interventions. Adoption of interventions and practices is part of clinical implementation. Determination of the basis of disease and treatment options is part of the preclinical research phase. Exploration of the fundamental mechanisms of biology, disease, or behavior is part of the basic research stage. Which statement made by a health care provider demonstrates the most appropriate understanding for the goal of a performance report? a. "This process allows me to critique the performance of the rest of the staff." b. "Most organizations require staff to undergo a performance evaluation yearly." c. "It is hard to be personally criticized but that's how we learn to change." d. "The comments should help me improve my management skills." ANSWERS ANS: D The goal of the performance report is to provide guidance to staff in the areas of professional development, mentoring, and leadership development. A peer review is written by others who perform similar skills (peers). The remaining options may be true but do not provide evidence of understanding of the goal of this professional requirement. Which assessment question would a health care provider ask when engaging in the previsit stage of the new model for primary care? (Select all that apply.) a. "Are you ready to discuss some of the community resources that are available?" b. "Are you experiencing any side effects from your newly prescribed medications?" c. "Do you anticipate any problems with adhering to your treatment plan?" d. "Are you ready to discuss the results of your laboratory tests?" e. "Do you have any questions about the lab tests that have been ordered for you?" ANSWERS ANS: B, C, E The nursing responsibilities in the previsit stage include assessing the patient's tolerance of prescribed medications, understanding of existing treatment plan, and education about required lab testing. The primary care provider is responsible for screening lab data and discussing community resources during the actual visit. What is the Quadruple Aim? p. 15 ANSWERS 1) Improved patient satisfaction 2) Reduce per capita costs 3) Improve population health 4) Improve patient care team experience To reduce adverse events associated with care transitions, the Centers for Medicare and Medicaid Service have implemented which policy? a. Mandates for communication among primary caregivers and hospitalists b. Penalties for failure to perform medication reconciliations at time of discharge c. Reduction of payments for patients readmitted within 30 days after discharge d. Requirements for written discharge instructions for patients and caregivers ANSWERS ANS: C As a component of the Affordable Care Act, the Centers for Medicare and Medicaid Service developed the Readmissions Reduction Program reducing payments for certain patients readmitted within 30 days of discharge. The CMS did not mandate communication, institute penalties for failure to perform medication reconciliations, or require written discharge instructions. According to multiple research studies, which intervention has resulted in lower costs and fewer rehospitalizations in high-risk older patients? a. Coordination of posthospital care by advanced practice health care providers b. Frequent posthospital clinic visits with a primary care provider c. Inclusion of extended family members in the outpatient plan of care d. Telephone follow-up by the pharmacist to assess medication compliance ANSWERS ANS: A Research studies provided evidence that high-risk older patients who had posthospital care coordinated by an APN had reduced rehospitalization rates. It did not include clinic visits with a primary care provider, inclusion of extended family members in the plan of care, or telephone follow-up by a pharmacist 1. Which advantages are provided to the chronically ill patient by personal electronic monitoring devices? (Select all that apply.) a. Helps provide more patient control their health and lifestyle b. Eliminates need for regular medical and nursing follow-up visits c. Helps the early identification of patient health-related problems d. Helps health care providers in keeping track of the patient's health status e. Cost is often covered by Medicare ANSWERS ANS: A, C, D, E A primary care provider administers the "Newest Vital Sign" health literacy test to a patient newly diagnosed with a chronic disease. What information is gained by administering this test? a. Ability to calculate data, along with general knowledge about health b. Ease of using technology and understanding of graphic data c. Reading comprehension and reception of oral communication d. Understanding of and ability to discuss health care concerns ANSWERS ANS: A The "Newest Vital Sign" tests asks patients to look at information on an ice cream container label and answer questions that evaluate ability to calculate caloric data and to grasp general knowledge about food allergies. It does not test understanding of technology or directly measure reading comprehension. It does not assess oral communication. The "Ask Me 3" tool teaches patients to ask three primary questions about their health care and management. What is the main reason for using the REALM-SF instrument to evaluate health literacy? p. 27 a. It assesses numeracy skills. b. It enhances patient-provider communication. c. It evaluates medical word recognition. d. It measures technology knowledge. ANSWERS ANS: C The Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) is an easy and fast tool that measures medical word recognition. It does not evaluate numeracy. The "Ask Me 3" tool enhances patient-provider communication. This tool does not evaluate understanding of technology. A female patient who is from the Middle East schedules an appointment in a primary care office. To provide culturally responsive care, what will the clinic personnel do when meeting this patient for the first time? a. Ensure that she is seen by a female provider. b. Include a male family member in discussions about health care. c. Inquire about the patient's beliefs about health and treatment. d. Research middle eastern cultural beliefs about health care. ANSWERS ANS: C It is important not to make assumptions about beliefs and practices associated with health care and to ask the patient about these. While certain practices are common in some cultural and ethnic groups, assuming that all members of those groups follow those norms is not culturally responsive. A primary care provider is providing care for a postsurgical client who recently immigrated to the United States and speaks English only marginally. What intervention will provide the most effective means of communicating postdischarge information to the client? a. Postpone discharge until the client is fully recovered from the surgery. b. Requesting that a family member who speaks English be present during the teaching session c. Providing the necessary information in written form in the client's native language d. Requesting the services of a professional interpreter fluent in the client's native language ANSWERS ANS: D Only approved, professional interpreters experienced in health care interpretation are appropriate interpreters for patients. Family members or friends should not be used as interpreters. Use of family members or friends may create misinterpretation or misunderstanding between the provider and the patient. Family members may not understand medical terms or may interpret only what they feel is important, or patients might feel uncomfortable divulging personal information to the person interpreting. Written information in the client's native language may be a means of reinforcing instructions but are not a substitute of person-to-person education. It is neither realistic nor necessary to postpone discharge for this reason. What question asked by the client newly diagnosed with congestive heart failure demonstrates the effectiveness of previous education concerning the Ask Me 3 health literacy tool? p. 31 (Select all that apply.) a. "Where can I get assistance with the cost of my medications?" b. "Why is it important for me to take this newly prescribed medication?" c. "Is it true that high blood pressure isn't causing my problem?" d. "Is congestive heart failure curable with appropriate treatment?" e. "Would watching my intake of salt help me manage this problem? ANSWERS ANS: B, C, E While all these questions are appropriate, the Ask Me 3 tool encourages the client to question what the problem is, what they need to do to manage the problem, and why it is important to follow the treatment plan. Financial support and curability of the problem is not directly addressed by this tool. A patient expresses concern that she is at risk for breast cancer. To best assess the risk for this patient, what is the best initial action? a. Ask if there is a family history of breast cancer. b. Gather and record a three-generation pedigree. c. Order a genetic test for the breast cancer gene. d. Recommend direct-to-consumer genetic testing. ANSWERS ANS: B The three-generation pedigree is the best way to evaluate genetic risk. Asking about a family history is not a systematic risk assessment and does not specify who in the family has the history or whether there is a pattern. Genetic testing and direct-to-consumer (DTC) genetic testing are not the initial actions when assessing genetic risk. A patient asks about direct-to-consumer (DTC) genetic testing. What will the provider tell the patient? p. 42 a. It is not useful for identifying genetic diseases. b. Much of the information does not predict disease risk. c. The results are shared with the patient's insurance company. d. The results must be interpreted by a provider. ANSWERS ANS: B DTC testing gives a lot of information, but much of it does not contribute to disease prediction, since mutations are not necessarily related to specific diseases. The tests are useful but must be interpreted accurately. The results are confidential and do not have to be interpreted by a provider. What is an important part of patient care that can minimize the risk of a formal patient complaint even when a mistake is made? p. 49 a. Ensuring informed consent for all procedures b. Maintaining effective patient communication c. Monitoring patient compliance and adherence d. Providing complete documentation of visits ANSWERS ANS: B Effective patient communication is key to building trust and rapport and ineffective communication is a predictor for malpractice claims. The other items are important aspects of care and may help the provider during the investigation of a claim, but do not minimize the risk. What are some causes for failures or delays in diagnosing patients resulting in malpractice claims? (Select all that apply.) a. Failing to recognize a medication complication b. Failing to request appropriate consultations c. Improper performance of a treatment d. Not acting on diagnostic test results e. Ordering a wrong medication ANSWERS ANS: B, D Failing to obtain consultations when indicated or not acting on diagnostic test results can lead to diagnosis-related failures. Failing to recognize medication complications and ordering a wrong medication lead to medication prescribing allegations. Improper performance of a treatment can lead to treatment-related malpractice claims. A primary care provider is performing a Tzanck test to evaluate possible herpes simplex lesions. To attain accurate results, the provider will perform what intervention? p. 232 a. Blanch the lesions while examining them with a magnifying glass. b. Gently scrape the lesions with a scalpel onto a slide. c. Perform a gram stain of exudate from the lesions. d. Remove the top of the vesicles and obtain fluid from the lesions. ANSWERS ANS: D The Tzanck test requires removing the tops from vesicular lesions in order to obtain fresh fluid from the base of the lesions. Blanching of blue to red lesions under a microscope helps to evaluate whether blood is in the capillaries of the lesions. Scraping lesions onto a slide is done to evaluate the presence of hyphae and spores common with candidiasis or fungal infections. Gram staining is performed to distinguish gram-positive from gram-negative organisms in suspected bacterial infections. When examining a patient's skin, a practitioner uses dermoscopy for what purpose? p. 232 (Select all that apply.) a. Accentuating changes in color of pathologic lesions by fluorescence b. Assessing changes in pigmentation throughout various lesions c. Determining whether lesion borders are regular or irregular d. Differentiating fluid masses from cystic masses in the epidermis e. Visualizing skin fissures, hair follicles, and pores in lesions ANSWERS ANS: B, C, E Dermoscopy is used to visualize the epidermis and superficial dermis and can reveal changes in pigmentation throughout lesions, whether borders are regular or irregular, and the various fissures, follicles, and pores present in lesions. The Wood's light, or black light, is used to fluoresce lesions to accentuate changes in color. A direct light source is useful for differentiating fluid masses from cystic masses. A patient has actinic keratosis and the provider elects to use cryosurgery to remove the lesions. How will the provider administer this procedure? p. 234 a. Applying one or two freeze-thaw cycles to each lesion b. Applying two or more freeze-thaw cycles to each lesion c. Applying until the freeze spreads laterally 1 mm from the lesion edges d. Applying until the freeze spreads laterally 4 mm from the lesion edges ANSWERS ANS: A For actinic keratosis, one to two freeze-thaw cycles are usually enough. Two or more freeze-thaw cycles are generally required for thicker, seborrheic keratosis lesions. The freeze should spread laterally 3 to 4 mm from the edge of the lesions. A provider is preparing to administer electrocautery to a patient who has several seborrheic keratoses. The patient tells the provider that he has a pacemaker. Which action is correct? a. Administer the electrocautery per the usual protocol. b. Apply electrocautery in short burst at low voltage. c. Refer the patient to a dermatologist for removal. d. Suggest another method for removal of the lesions. ANSWERS ANS: B Patients with pacemakers or implantable cardioverter-defibrillators may receive electrocautery if appropriate precautions, such as lower voltage and shorter bursts are taken. It is not necessary to suggest another method or to refer to a dermatologist. Which type of office surgical procedure warrants sterile technique? a. Curettage b. Punch biopsy c. Scissor excision d. Shave biopsy ANSWERS ANS: B Punch biopsy requires sterile technique. The other procedures require cleaning with alcohol and clean technique with universal precautions. When recommending an over-the-counter topical medication to treat a dermatologic condition, which instruction to the patient is important to enhance absorption of the drug? a. Apply a thick layer of medication over the affected area. b. A solution spray preparation will be more effective on hairy areas. c. Put cool compresses over the affected area after application. d. Use a lotion or cream instead of an ointment preparation. ANSWERS ANS: B Hairy areas are difficult to penetrate, so in these areas, a solution, foam, spray, or gel may work better. Applying a thicker layer does not increase skin penetration or effectiveness of a medication. Warm or inflamed skin absorbs medications more readily; cool compresses will decrease absorption. Lotions and creams are not as readily absorbed as ointments, which have occlusive properties. A provider is prescribing a topical dermatologic medication for a patient who has open lesions on a hairy area of the body. Which vehicle type will the provider choose when prescribing this medication? a. Cream b. Gel c. Ointment d. Powder ANSWERS ANS: B Gels are an excellent vehicle for use on hairy areas of the body. Creams and ointments are not recommended for hairy areas. Powders should be avoided in open wounds. An adult patient has been diagnosed with atopic dermatitis and seborrheic dermatitis with lesions on the forehead and along the scalp line. Which is correct when prescribing a corticosteroid medication to treat this condition? p. 238 a. Initiate treatment with 0.1% triamcinolone acetonide. b. Monitor the patient closely for systemic adverse effects during use. c. Place an occlusive dressing over the medication after application. d. Prescribe 0.05% fluocinonide to apply liberally. ANSWERS ANS: A Treatment with 0.1% triamcinolone acetonide is appropriate in this case, because it is a class 4 corticosteroid and may be used on the face and is suggested for use for these conditions. Systemic side effects are rare when topical corticosteroids are used appropriately. Occlusive dressings increase the risk of adverse effects and are not recommended. 0.05% fluocinonide is a class III corticosteroid and should not be used on the face. During a total body skin examination for skin cancer, the provider notes a raised, shiny, slightly pigmented lesion on the patient's nose. What will the provider do? a. Consult with a dermatologist about possible melanoma. b. Reassure the patient that this is a benign lesion. c. Refer the patient for possible electrodessication and curettage. d. Tell the patient this is likely a squamous cell carcinoma. ANSWERS ANS: C This lesion is characteristic of basal cell carcinoma, which is treated with electrodessication and curettage. Melanoma lesions are usually asymmetric lesions with irregular borders, variable coloration, 6 mm diameter, which are elevated; these should be referred immediately. All suspicious lesions should be biopsied; until the results are known, the provider should not reassure the patient that the lesion is benign. Squamous cell carcinoma is roughened, scaling, and bleeds easily. What is the initial approach when obtaining a biopsy of a potential malignant melanoma lesion? a. Excisional biopsy b. Punch biopsy c. Shave biopsy d. Wide excision ANSWERS ANS: A A suspected malignant melanoma lesion should be biopsied with excisional biopsy; if diagnosed, a wide excision should follow. Punch and shave biopsy procedures are appropriate for diagnostic evaluation of NMSC lesions. A patient has acne and the provider notes lesions on half of the face, some nodules, and two scarred areas. Which treatment will be prescribed? a. Oral clindamycin for 6 to 8 weeks b. Oral isotretinoin c. Topical benzoyl peroxide and clindamycin d. Topical erythromycin ANSWERS ANS: C This patient has moderate acne, based on symptoms of lesions on half of the face with nodules and a few scars. A combination of topical benzoyl peroxide and clindamycin is recommended. Oral antibiotics are reserved for severe cases. Oral isotretinoin is used only for recalcitrant cases which are severe and have not responded to other treatments. Topical antibiotics should be used as monotherapy. A provider is considering an oral contraceptive medication to treat acne in an adolescent female. Which is an important consideration when prescribing this drug? p. 246 a. A progesterone-only contraceptive is most beneficial for treating acne. b. Combined oral contraceptives are effective for non-inflammatory acne only. c. Oral contraceptives are effective because of their androgen enhancing effects. d. Yaz, Ortho Tri-Cyclen, and Estrostep, are approved for acne treatment. ANSWERS ANS: D Three oral contraceptives have a labeled use for acne treatment: Yaz, Ortho Tri-Cyclen, and Estrostep. Progesterone-only contraceptives may worsen acne. Combined oral contraceptives are effective in reducing inflammatory and non-inflammatory acne. Oral contraceptives are effective because of their antiandrogen effects, since androgen induces sebum production. A female patient is diagnosed with hidradenitis suppurativa and has multiple areas of swelling, pain, and erythema, along with several abscesses in the right femoral area. When counseling the patient about this disorder, the practitioner will include which information? p. 252 a. Antibiotic therapy is effective in clearing up the lesions. b. It is often progressive with relapses and permanent scarring. c. The condition is precipitated by depilatories and deodorants. d. The lesions are infective, and the disease may be transmitted to others. ANSWERS ANS: B Although lesions may be treated with antibiotics, other medications, and drainage, the disease is often progressive, with relapses and permanent scarring. Deodorants and depilatories are not implicated as a cause. The disease is not transmitted to others, although the organisms may cause other infections in other people. When counseling a patient with rosacea about management of this condition, the provider may recommend (Select all that apply.) a. applying a topical steroid. b. avoiding makeup. c. avoiding oil-based products. d. eliminating spicy foods. e. exposing the skin to sun. f. using topical antibiotics. ANSWERS ANS: C, D, F Patients with rosacea should avoid oil-based products and eliminate spicy foods, alcohol, and hot fluids. Topical antibiotics may be used if pustules are present. Topical steroids are not recommended. Patients do not need to avoid makeup and should avoid the sun. Which medications may be used as part of the treatment for a patient with hidradenitis suppurativa? (Select all that apply.) a. Chemotherapy b. Erythromycin c. Infliximab d. Isotretinoin e. Prednisone ANSWERS ANS: B, C, D, E Hidradenitis suppurativa is not malignant and chemotherapy is not used. Erythromycin, infliximab, isotretinoin, and prednisone are all used. A patient is seen in the clinic for patches of hair loss. The provider notes several well-demarcated patches on the scalp and eyebrows without areas of inflammation and several hairs within the patch with thinner shafts near the scalp. Based on these findings, which type of alopecia is most likely? a. Alopecia areata b. Anagen effluvium c. Cicatricial alopecia d. Telogen effluvium ANSWERS ANS: A These findings are characteristic of alopecia areata. Anagen effluvium and telogen effluvium both result in diffuse hair loss and not discrete patches. Cicatricial alopecia involves inflammation. A patient diagnosed with alopecia is noted to have scaling on the affected areas of the scalp. Which confirmatory test(s) will the provider order? a. Examination of scalp scrapings with potassium hydroxide (KOH) b. Grasping and pulling on a few dozen hairs c. Serum iron studies and a complete blood count d. Venereal Disease Research Laboratory (VDRL) test ANSWERS ANS: A Scaling on the scalp is suggestive of tinea capitis. To confirm this, the provider will perform scalp scraping or test hair samples with KOH preparation to look for hyphae. Grasping and pulling on hairs is used to identify anagen or telogen hairs by appearance. Serum iron and aCBC are used if anemia is suspected as a cause. VDRL is performed if syphilis is suspected. A female patient is diagnosed with androgenetic alopecia. Which medication will the primary health care provider prescribe? a. Anthralin b. Cyclosporine c. Finasteride d. Minoxidil ANSWERS ANS: D Either minoxidil or finasteride are used for androgenetic alopecia, but finasteride is Pregnancy Category X, so minoxidil is the only medication approved by the FDA for use in women. Anthralin and cyclosporine are used to treat alopecia areata. A young adult has been bitten by a dog resulting in several puncture wounds near the thumb of one hand but can move all fingers and the bleeding has stopped. What understanding regarding dog bites should direct the care of this patient? a. Infection is a likely outcome for a dog bite. b. Dog bites generally result in serious injury. c. Neurovascular and destructive soft tissue injuries can occur from such a bite. d. Oral antibiotics are needed to address the increased risk for the development of osteomyelitis. ANSWERS ANS: C Dog bites account for most of the domestic animal bites that require medical care, yet dog bites have had the lowest incidence of wound infection (2% to 13%). Even though most dog bites are relatively minor, severe injuries can occur. These can include crush injuries, destructive soft tissue injuries, neurovascular injuries, orthopedic injuries, and death. Osteomyelitis is a risk for human bites. A patient has sustained a human bite on the hand during a fist fight. Which is especially concerning with this type of bite injury? a. Possible exposure to rabies virus b. Potential septic arthritis or osteomyelitis c. Sepsis from Capnocytophaga canimorsus infection d. Transmission of human immunodeficiency virus ANSWERS ANS: B Clenched-fist injury, or "fight bite," has a high complication rate from the high penetrating force with the potential for osteomyelitis, tendinitis, and septic arthritis. Humans do not transmit rabies unless infected, which is highly unlikely. Humans do not transmit C. canimorsus. HIV transmission is potential, but the risk is extremely low. Which type of bite is generally closed by delayed primary closure? (Select all that apply.) p. 262 a. Bites to the face b. Bites to the hand c. Deep puncture wounds d. Dog bites on an arm e. Wounds 6 hours old or older ANSWERS ANS: B, C, E Cat and human bites, deep puncture wounds, clinically infected wounds, wounds more than 6 to 12