Question 1

The primary care NP is reviewing evidence-based recommendations about the off-label use of a particular drug.Which recommendation should influence the NP's decision about prescribing the medication?&#10;A) Data from randomized, experimental studies&#10;B) Patient reports about effectiveness of the drug for this purpose&#10;C) Pharmaceutical company reports using anecdotal evidence&#10;D) Endorsement of this use by a leading practitioner in the field

Accepted Answer

Randomized,experimental studies yield the best data about use of medications.Patient reports carry the least weight because bias can occur and other factors can influence outcomes.Pharmaceutical company reports are biased.

Question 2

A patient comes to the clinic reporting dizziness and fatigue associated with nausea and vomiting.The primary care NP suspects anemia and orders a complete blood count.The patient's hemoglobin is elevated.The NP correctly concludes that the patient is not anemic.The NP has made an error in:

A) context formulation.
B) inappropriate knowledge base.
C) cost-versus-benefit analysis.
D) hypothesis triggering and information processing.

Accepted Answer

Faulty hypothesis triggering occurs when the clinician fails to consider appropriate initial hypotheses.The patient had nausea and vomiting,which can cause dehydration,leading to orthostatic hypotension and dizziness.The NP made an assumption that the dizziness was caused by anemia and ordered a complete blood count.Faulty information gathering occurs when clinicians fail to order appropriate tests.An error in context formulation occurs when clinicians and patients have different goals.Errors in knowledge base would occur if the practitioner did not perform a complete history and physical,missing important information.An error in cost-versus-benefit analysis could occur if the clinician ordered expensive tests that were not necessary for diagnosis and treatment.

Question 3

A patient comes to the clinic and asks the primary care NP about using a newly developed formulation of the drug the patient has been taking for a year.When deciding whether or not to prescribe this formulation,the NP should:

A) tell the patient that when postmarketing data is available, it will be considered.
B) review the pharmaceutical company promotional materials about the new medication.
C) prescribe the medication if it is less expensive than the current drug formulation.
D) prescribe the medication if the new drug is available in an extended-release form.

Accepted Answer

About 6 to 12 months of postmarketing experience can yield information about drug efficacy and side effects,so patients should be cautioned to wait for these data.Drug company promotional materials have biased information.Most new drugs are more expensive,and costs alone should not determine drug choice.Extended-release forms are often more expensive.

Question 4

A primary care NP is developing a clinical practice guideline for management of a patient population in a midsized suburban hospital.The NP should:&#10;A) use an existing guideline from a leading research hospital.&#10;B) follow the guideline provided by a third-party payer to help ensure reimbursement.&#10;C) review expert opinion and experimental, anecdotal, correlational study data.&#10;D) write the guideline to adhere to long-standing practice protocols already in use.

Accepted Answer

Clinical guidelines should be written using all available evidence as well as expert opinion.Existing guidelines from a different type of hospital may not be based on data generalizable to this population.Third-party payer guidelines are usually weighted toward decreased costs.Long-standing protocols often do not take into account current knowledge and research.

Question 5

The primary care NP has referred a child who has significant gastrointestinal reflux disease to a specialist for consideration for a fundoplication and gastrostomy tube placement.The child's weight is 80% of what is recommended for age,and a recent swallow study revealed significant risk for aspiration.The child's parents do not want the procedure.The NP should:

A) compromise with the parents and order a nasogastric tube for feedings.
B) initiate a discussion with the parents about the potential outcomes of each possible action.
C) refer the family to a case manager who can help guide the parents to the best decision.
D) understand that the child's parents have a right to make choices that override those of the medical team.

Accepted Answer

In general,the goal of a health care decision maker is to choose an action that is most likely to deliver the outcomes the patient wants.Initiating a discussion about outcomes helps parents decide based on end results.A nasogastric tube is not the best choice for the child,and compromising without first exploring options is incorrect.As part of the therapeutic relationship,the NP should be involved with patients' decisions.Although patients and families have the right to make decisions,the NP has an obligation to ensure that the decisions are informed decisions.

Question 6

A patient takes a cardiac medication that has a very narrow therapeutic range.The primary care NP learns that the particular brand the patient is taking is no longer covered by the patient's medical plan.The NP knows that the bioavailability of the drug varies from brand to brand.The NP should:

A) contact the insurance provider to explain why this particular formulation is necessary.
B) change the patient's medication to a different drug class that doesn't have these bioavailability variations.
C) accept the situation and monitor the patient closely for drug effects with each prescription refill.
D) ask the pharmaceutical company that makes the drug for samples so that the patient does not incur out-of-pocket expense.

Accepted Answer

In this case,the NP should advocate for the desired drug because changing the drug can have life-threatening consequences.If this fails,other options may have to be explored.

Question 7

A patient comes to the clinic with a 2-day history of cough and wheezing.The patient has no previous history of asthma.The patient reports having heartburn for several months,which has worsened considerably.The primary care NP makes a diagnosis of asthma and orders oral steroids and inhaled albuterol.The patient's condition worsens,and a chest radiograph obtained 2 days later shows bilateral infiltrates.The NP has failed to:

A) confirm the diagnosis.
B) determine the aggressiveness of therapy.
C) prescribe an adequate dose of medications.
D) allow the drugs an adequate amount of time to work.

Accepted Answer

This patient had symptoms that could occur with both asthma and aspiration pneumonia.The NP failed to confirm the diagnosis and prescribed the wrong treatment,leading to worsening of symptoms.

Question 8

The primary care nurse practitioner (NP)is using critical thinking skills when:&#10;A) using standardized protocols to guide patient care.&#10;B) adhering to scientific principles to solve a patient problem.&#10;C) following the practices of seasoned mentors when giving care.&#10;D) analyzing current research and synthesizing new approaches to patient care.

Accepted Answer

Practitioners use critical thinking skills by reviewing and analyzing current knowledge and synthesizing approaches to apply to unique patient situations.Using standardized protocols,adhering to scientific principles,and following practices of seasoned mentors may be useful,but these do not encompass the concept of critical thinking,which requires the practitioner to use what is known in new situations.

Question 9

The primary care NP prescribes an inhaled corticosteroid for a patient who has asthma.The third-party payer for this patient denies coverage for the brand that comes in the specific strength the NP prescribes.The NP should:

A) provide pharmaceutical company samples of the medication for the patient.
B) inform the patient that the drug must be paid for out of pocket because it is not covered.
C) order the closest formulary-approved approximation of the drug and monitor effectiveness.
D) write a letter of medical necessity to the insurer to explain the need for this particular medication.

Accepted Answer

The second step of medical decision making takes into account benefits versus costs along with an understanding that it is impossible to do everything because of limited resources.The NP should prescribe what is covered and evaluate its effectiveness; if it does not work,the third-party payer may be approached about the need for the other medication.Providing samples is not always possible,and this practice is being discouraged,so it is not a viable solution.Asking patients to pay out of pocket ultimately may be necessary but carries risks that the patient will not obtain the medication.Writing a letter of medical necessity may be indicated if the available drugs are not effective but is not the initial step.

Deck 11: Evidence-Based Decision Making and Treatment Guidelines