NSG 555 Quiz 1

Which specialties have the highest malpractice claims in the NP claim report?

Neonatal and pediatric.

Which practice settings put a nurse practitioner at higher risk of a claim?

Underserved areas.

Aging services facilities (nursing homes). Nurse practitioner office practice.

Behavioral health and psychiatric facilities.

The emergency room.

What are the practices that reduce a nurse practitioner's malpractice risk?

1) Practice within the limits of your state's Nurse Practice Act.

2) Follow your organization's policies and procedures, and stay within the standard of care.

3) Document assessments, observations, conversations, and actions objectively, promptly, and completely.

4) Use the chain of command or risk management when you have a concern about a patient or about your practice.

5) Communicate appropriately.

6) Document thoroughly.

7) Manage adverse events effectively.

8) Assess patients in detail.

9) Document informed consent well.

10) Explain treatments and the referral process clearly.

What do you do when an error or adverse medical event occurs?

1) Report it to your clinical supervisor or the risk manager, following your organization's policy.

2) Complete an incident report.

What are the general principles of geriatric care?

1) Most problems in older adults have SEVERAL causes at once, so they usually need several interventions at once.

2) Disease often shows up ATYPICALLY - instead of the classic symptoms, you see confusion or a decline in function.

3) Not every abnormal finding needs to be worked up and treated. 4) Multiple chronic conditions and geriatric syndromes usually coexist, and they should be managed together rather than one at a time in isolation.

What are the geriatric 5 Ms?

1) MIND - dementia, delirium, and depression.

2) MOBILITY - immobility, falls, and gait problems.

3) MEDICATIONS - polypharmacy, meaning too many drugs or inappropriate ones.

4) MULTICOMPLEXITY - the whole picture, which guides treatment decisions.

5) What MATTERS MOST - the patient's own values and goals.

What does 'multicomplexity' mean in geriatric assessment?

It goes beyond the usual list of symptoms, diseases, and medications. It takes in the patient's biological, psychological, and social situation, and it includes an honest look at prognosis, the patient's values and preferences, and how independently they can still function.

How does prognosis change what tests and treatments you offer an older adult?

If life expectancy is under 10 years - especially if it is much less - choose tests and treatments based on whether they can actually change an outcome the patient cares about within the time they have. A screening test that takes 10 years to show benefit does not help someone with 3 years to live.

Why do you need to ask an older adult about their values and preferences?

Because many frail older adults would rather keep their INDEPENDENCE than live longer, and you cannot assume which they would choose. Their priorities can also shift over time, so this is a conversation you revisit, not a box you check once.

What belongs in a functional screening of an older patient?

Assess activities of daily living. Ask questions that would surface weight loss, falls, incontinence, depressed mood, self-neglect, fear for personal safety, and common serious impairments in vision, thinking, and mobility. Also ask whether they have GIVEN UP a favorite activity like bowling or gardening - that often reveals a decline before a formal test does.

What are the elements of frailty? (Need 3 of 5)

1) Weakness, measured as reduced grip strength.

2) Slow walking speed.

3) Decreased physical activity.

4) Weight loss.

5) Exhaustion or low energy.

Having three or more of these defines frailty.

What is the purpose of the Beers Criteria?

1) To reduce older adults' exposure to potentially inappropriate medications - drugs whose risks usually outweigh their benefits in people over 65.

2) To educate clinicians and patients.

3) To serve as a tool for evaluating quality of care, cost, and prescribing patterns in older adults.

What is palliative care?

Medical care focused on improving quality of life for people living with a serious illness - meaning an illness that carries a high risk of death, harms quality of life and daily function, and/or is burdensome because of its symptoms, its treatment, or the strain it puts on caregivers.

When can palliative care be provided?

Alongside treatment meant to prolong life - it is not limited to the end of life. Near the end of life it may become the only focus of care, but it can start at diagnosis.

What are the basics of delivering palliative care?

1) Routinely look for symptoms and take the first steps to manage them.

2) Talk about prognosis and find out what the patient wants from their care.

3) Help identify and address whatever is causing distress - which may be physical, emotional, spiritual, or practical.

How do you approach a conversation about prognosis?

Ask PERMISSION before discussing it. Then ask HOW they want to receive information: directly to them, through a family member, or not all of it at all. Some patients want every number and some want none.

What are the steps for communicating about serious illness?

1) Get consent to have the conversation.

2) Find out what the patient and family already understand.

3) Give the clinical information briefly and directly, without jargon.

4) Allow silence and time for emotion.

5) Make the decision collaboratively.

6) Briefly summarize what was said and what happens next.

What is advance care planning?

A process that helps adults at any age or stage of health understand and share their personal values, life goals, and preferences about future medical care. It is a conversation, not a form.

What is the goal of advance care planning?

To make sure people receive medical care that matches their own values, goals, and preferences during serious and chronic illness - including at times when they can no longer speak for themselves.

What does advance care planning involve doing?

Naming a surrogate decision-maker. Actually TALKING to that person about what you would want. Documenting those wishes so they can be found later.

What is an advance directive?

A written or spoken statement a patient makes WHILE THEY STILL HAVE CAPACITY, meant to guide their care if they later lose the ability to make and communicate decisions.

How should you frame a conversation about CPR with someone whose prognosis is short?

The question is not whether they will live or die - it is HOW they will die. Framing it as a survival decision is misleading when survival is not on the table.

What should advance directives address besides stopping treatment?

Which interventions will be CONTINUED or STARTED to promote comfort - not only which ones will be stopped or withheld. A directive written entirely in negatives leaves out the care the patient will actually receive.

What is a Durable Power of Attorney for Health Care?

A surrogate decision-maker appointed by the patient. Their job is to use SUBSTITUTED JUDGMENT - deciding what the PATIENT would have wanted, not what the surrogate would want - once the patient can no longer decide or communicate.

What is a POLST?

Physician Orders for Life-Sustaining Treatment. Unlike an advance directive, which is a statement of wishes, a POLST is a set of ACTIVE MEDICAL ORDERS, including about resuscitation. It complements the advance directive and is what actually guides care in an emergency.

What are somatic, visceral, and neuropathic pain?

SOMATIC - pain arising from tissues such as skin, muscle, and bone.

VISCERAL - pain arising from internal organs.

NEUROPATHIC - pain arising from damage to nerves or nerve roots.

How are acute, subacute, and chronic pain defined by duration?

ACUTE - less than 1 month.

SUBACUTE - 1 to 3 months.

CHRONIC - more than 3 months.

What is first-line drug therapy for neuropathic pain?

Gabapentin, starting at 100 to 300 mg daily and titrating up gradually. Start low in older adults because of sedation and fall risk.

What else can be used for neuropathic pain besides gabapentin?

SNRIs (serotonin-norepinephrine reuptake inhibitors) - duloxetine and venlafaxine; avoid venlafaxine in cardiac patients. Tricyclic antidepressants - nortriptyline and desipramine.

DO NOT combine an SNRI with a tricyclic, because of serotonin syndrome risk. Lidocaine patches are also an option. Note that tricyclics are on the Beers list, so use them cautiously in older adults because of confusion and falls.

What are the rules when you do prescribe an opioid?

Use an immediate-release formulation. Use the lowest dose that works. Be cautious if the patient is also taking a benzodiazepine or another medication that depresses the central nervous system. Prescribe only enough for the expected duration of pain. Set goals for both pain and function up front, and discuss how the opioid will eventually be stopped.

How do you manage pain after surgery?

Use a multimodal, opioid-SPARING approach: patient-controlled analgesia, regional anesthesia (nerve blocks), ketamine, gabapentinoids, and COX inhibitors such as NSAIDs. Note that opioids are minimized, not forbidden - they still have a role after invasive surgery with moderate to severe pain, but they should never be the whole plan.

How is chronic pain that is NOT from cancer managed?

It needs interdisciplinary management. Physical therapy and cognitive behavioral therapy are the most effective components.

Should you prescribe opioids for chronic low back pain?

NO.

What is the WHO ladder for chronic cancer pain?

Start with non-opioid analgesics. Step up to weak opioids. Step up to strong opioids. Other options alongside the ladder include nerve blocks and implantable devices.

How is chronic cancer pain treated with opioids?

A long-acting opioid given around the clock, with a short-acting one available for breakthrough pain. Expect to adjust the dose frequently as the disease changes.

What about opioid dosing in a dying patient?

It is acceptable to exceed the doses recommended for acute pain. The goal has shifted entirely to comfort.

What is a cataract?

Clouding (opacification) of the lens of the eye.

What are the symptoms of cataracts?

Decreased visual sharpness and GLARE - trouble with headlights at night and with bright sunlight.

What causes cataracts?

Usually just aging. Diabetes and smoking also contribute.

What are the three types of cataract?

Nuclear, cortical, and posterior subcapsular - named for where in the lens the clouding sits.

What is the classic clinical picture of cataracts?

PAINLESS, GRADUAL vision loss in BOTH eyes, with particular difficulty seeing at night. Peripheral vision is preserved. A ___ blurs the WHOLE visual field, central vision included. What stays intact is the peripheral field.

How are cataracts treated?

Surgical removal of the lens with an artificial intraocular lens implanted in its place. There is NO drug treatment.

What is macular degeneration?

Loss of CENTRAL vision, caused by damage to the macula - the small central part of the retina responsible for sharp, detailed sight.

What causes macular degeneration?

Aging, genetics, and environmental factors.

What are the two types of macular degeneration?

DRY (non-neovascular) - the more common, slower form. WET (neovascular) - abnormal new blood vessels grow and leak; it progresses much more rapidly.

What are the risk factors for macular degeneration?

Age, smoking, family history, and a diet low in antioxidants.

Why does macular degeneration matter so much?

It is the leading cause of CENTRAL vision loss in DEVELOPED countries, and the vision lost is IRREVERSIBLE. (CORRECTION TO YOUR ORIGINAL CARD: it said developing countries.)

How is macular degeneration treated?

WET form: injections of anti-VEGF drugs into the eye to stop the abnormal vessels from leaking - urgent ophthalmology referral.

DRY form: no treatment reverses it; AREDS2 antioxidant and zinc supplements can slow progression in intermediate disease. Stop smoking, and give the patient an Amsler grid to check for new distortion at home.

What causes dry eye?

Medications, contact lenses, screen time, rheumatologic disease (such as Sjogren syndrome), and instability of the tear film itself.

What are the symptoms of dry eye?

Dryness, burning, blurry vision, and eye fatigue.

How is dry eye diagnosed?

Mainly on HISTORY. An ophthalmologist can do formal testing if needed.

What is first-line treatment for dry eye?

Artificial tears. Plus lifestyle changes - reduce screen time (and blink deliberately), warm compresses, stop smoking, and anti-inflammatory drops if needed.

What should patients understand about the course of dry eye?

It is chronic and relapsing, treatment has to be individualized, and it improves with CONSISTENCY. Patients who use drops only when symptomatic tend not to improve.

What are the three components of pulmonary function testing?

Spirometry, lung volumes, and DLCO.

What does spirometry measure?

How much air a person can breathe in or out, and how fast they can do it.

What is FEV1?

Forced Expiratory Volume in 1 second - the amount of air blown out in the FIRST SECOND of a hard, fast exhale.

What is Forced Vital Capacity (FVC)?

TOTAL amount of air blown out on that same hard exhale

What does the FEV1/FVC ratio tell you?

It is the fraction of the total exhaled air that comes out in the first second. Combined with whether it improves after a bronchodilator, it is what distinguishes asthma from COPD.

What do lung volumes measure, and why?

The total amount of air the lungs can hold and how much remains after blowing out fully. Their main job is detecting RESTRICTIVE lung disease, where the lungs cannot expand fully.

What is DLCO and what does it tell you?

Diffusing capacity for carbon monoxide - a measure of how well gas crosses from the air sacs into the blood, which reflects the health of the alveolar-capillary membrane.

A LOW DLCO points to interstitial lung disease, emphysema, or disease of the pulmonary blood vessels.

How long must a cough last to be called chronic?

8 weeks or more.

What are the main causes of chronic cough?

Upper airway cough syndrome (postnasal drip). Asthma. GERD (acid reflux). Nonasthmatic eosinophilic bronchitis.

What does a chronic cough typically sound and feel like?

Persistent, and usually DRY.

What symptoms point to upper airway cough syndrome as the cause?

Nasal congestion and frequent throat clearing.

What symptoms point to asthma as the cause of a chronic cough?

Wheezing, shortness of breath, and cough that is worse at NIGHT.

What symptoms point to reflux as the cause of a chronic cough?

Heartburn and regurgitation.

What might you find on physical exam in chronic cough?

Swollen nasal mucosa, cobblestoning of the posterior pharynx (from chronic postnasal drainage), and wheezing.

What test do you order for chronic cough?

A chest x-ray, once the cough has lasted 8 weeks or more.

What else belongs on the differential for chronic cough?

ACE inhibitors, which classically cause a dry hacking cough. Malignancy. Postnasal drip. Interstitial lung disease.

How do you treat upper airway cough syndrome?

A FIRST-generation antihistamine plus a decongestant. The first-generation drugs (such as diphenhydramine or chlorpheniramine) work here where the newer non-sedating ones do not - but they are on the Beers list, so be cautious in older adults.

How do you treat chronic cough caused by asthma?

Inhaled corticosteroids and bronchodilators.

How do you treat chronic cough caused by reflux?

A proton pump inhibitor.

Should you start several chronic cough treatments at once?

You CAN, but it is usually better to start ONE at a time so you can tell which one is working. If you do start several together, stop them one at a time for the same reason.

What should you think about when chronic cough does not respond to treatment?

Consider interstitial lung disease or malignancy. This patient needs a referral.

What is sarcoidosis?

A disease of unknown cause in which clusters of immune cells called granulomas form and cause inflammation, most prominently in the lungs (though it can affect many organs).

How is sarcoidosis diagnosed?

CHEST X-RAY shows enlarged lymph nodes at BOTH lung roots (bilateral hilar lymphadenopathy).

PULMONARY FUNCTION TESTS show a restrictive pattern.

BIOPSY shows NON-CASEATING granulomas - meaning no central necrosis, which is what distinguishes them from tuberculosis.

How is sarcoidosis treated?

PREDNISONE is clearly the drug of choice, and few patients fail to respond. Systemic corticosteroids are the treatment of choice. Methotrexate or infliximab if it persists.

Important exception: asymptomatic hilar adenopathy alone does NOT need to be treated.

If a patient's FEV1 is above 70% predicted, what does that suggest about their asthma treatment?

Consider stepping DOWN the controller therapy and reassessing in 2 to 4 weeks.

Conversely, if FEV1 is below 70% predicted, consider stepping UP for 3 months and then reassessing.

How do you confirm an asthma diagnosis?

The standard spirometry criterion is an FEV1 improvement of more than 12% AND more than 200 mL after a bronchodilator. Where spirometry is not available, the WHO PEN protocol uses peak expiratory flow: a rise of more than 20% measured 15 minutes after 2 puffs of salbutamol makes asthma likely.

Symptoms and peak flow improving after 4 weeks of inhaled corticosteroid also supports the diagnosis.

Can a LAMA be used alone in asthma?

NO - never as monotherapy. Always combine it with an inhaled corticosteroid. Examples are tiotropium and umeclidinium.

Asthma symptoms fewer than 4 to 5 days a week - what is the treatment?

As-needed low-dose ICS-formoterol only. The same inhaler serves as the reliever.

Asthma symptoms most days, or waking at night once a week or more - what is the treatment?

Low-dose MAINTENANCE ICS-formoterol, with as-needed low-dose ICS-formoterol as the reliever.

Asthma symptoms most days or night waking weekly, PLUS reduced lung function - what is the treatment?

MEDIUM-dose maintenance ICS-formoterol, with as-needed low-dose ICS-formoterol as the reliever.

Symptoms persist on medium-dose maintenance ICS-formoterol - what is next?

Add a LAMA.

Refer for phenotyping and/or biologic therapy.

Consider high-dose maintenance ICS-formoterol.

Keep the as-needed low-dose ICS-formoterol reliever.

When might oral corticosteroids be needed in asthma, and at what dose?

At step 4 or 5 (medium-dose ICS-formoterol or ICS-LABA and above) if the patient presents severely uncontrolled.

DOSE: prednisone or prednisolone 40 to 50 mg daily for 5 to 7 days in adults; no taper needed under 2 weeks.

Track 2 alternative: asthma symptoms less than twice a month

Take an inhaled corticosteroid whenever a short-acting reliever is taken. Alternatively use a combined ICS-SABA inhaler as the reliever.

Track 2 alternative: symptoms twice a month or more but fewer than 4 to 5 days a week

Low-dose maintenance inhaled corticosteroid, with a short-acting reliever or ICS-SABA as needed.

Track 2 alternative: symptoms most days, or waking with symptoms weekly

Low-dose maintenance ICS-LABA, with a short-acting reliever or ICS-SABA as needed.

Track 2 alternative: daily symptoms or weekly night waking PLUS reduced lung function

Medium- or high-dose maintenance ICS-LABA, with a short-acting reliever or ICS-SABA as needed.

Track 2 alternative: medium- or high-dose ICS-LABA is not enough

Add a LAMA. Refer for phenotyping and/or biologic therapy. Consider high-dose maintenance ICS-LABA. Keep the as-needed reliever.

How does the FEV1/FVC ratio differ between COPD and asthma?

COPD: the ratio stays below 0.70 even AFTER a bronchodilator - the obstruction is fixed.

Asthma: the ratio may drop during an attack but returns to normal (or near normal) after a bronchodilator or between episodes, because the obstruction is reversible.

How much does FEV1 improve after a bronchodilator in COPD?

It may improve somewhat, but by LESS than 12% - which is what separates it from asthma, where improvement is 12% or more AND at least 200 mL.

When is imaging indicated for low back pain?

When pain has not improved after 4 weeks of conservative treatment.

When do you order an MRI for back pain?

If the patient is not improving at 3 months. If NEW red flags appear. If there is acute radiculopathy with pain radiating PAST THE KNEE. If there are neurologic findings - notable weakness, numbness, or a lost reflex.

What are the indications for back imaging in general?

Severe or progressive neurologic deficits. Suspicion of a serious underlying condition such as infection, cancer, or cauda equina syndrome. Pain that has not improved with conservative treatment. When surgery or steroid injection is being considered.

When is IMMEDIATE imaging for back pain indicated?

It is NOT - routine immediate imaging is not indicated for ordinary low back pain. It is reserved for the red-flag situations (Loss of bladder or bowel control, saddle numbness, progressive leg weakness).

What clues suggest a systemic disease is causing back pain?

Age under 20 or over 50. Constant pain, especially if it is worse at night. Unexplained weight loss. A history of cancer.

What are the neurologic red flags for cauda equina syndrome?

Saddle anesthesia (numbness over the area that would touch a saddle). Urinary retention, or loss of bowel or bladder control. Loss of anal sphincter tone. Severe weakness or fixed numbness. This is a surgical emergency.

What clues suggest INFECTION is causing back pain?

Fevers. Chills. A chronic infection elsewhere. Immunosuppression. Current or past IV drug use.

Nerve root testing: L2, L3, L4, L5, S1 by MOTOR function

L2 - hip flexion.

L3 - knee extension.

L4 - ankle dorsiflexion, tested by HEEL walking.

L5 - great toe extension.

S1 - plantar flexion, tested by TOE walking.