Chapter 9 – Professional Issues & Trends

Question 1

What is the purpose of NP certification?

Answer 1

• Certification provides a process for validation of an advanced practice nurse’s qualifications and knowledge for practice as a nurse practitioner
• National NP certification is a part of the requirements for NP licensure in nearly all of the US states and will likely be a requirement of employment in the remaining states

Question 2

What are the nurse practice acts?

Answer 2

• A law that is enforced by each state’s nursing board

* Nurses at all levels must comply with the law and related rules in order to maintain their licenses

Question 3

What are the nurse practice act components?

Answer 3

• Qualifications for licensure – background checks, others
• Nursing titles that are allowed
• Scope of practice – varies state to state
• Actions that can or will happen if the nurse does not follow the nursing law

Question 4

What is credentialing?

Answer 4

• Provides practice authority in a given institution/healthcare setting
• Defines clinical and hospital privileges
• Enables insurance reimbursement

Question 5

What is a DEA number?

Answer 5

• Need a DEA number in order to prescribe controlled substances

Question 6

Schedule of controlled substances

Answer 6

• I – illegal for prescription (ex: heroin, MDMA, PCP)
• II – legal to prescribe with significant abuse potential (ex: morphine, fentanyl, methadone, oxycodone)
• III – meds with less abuse potential than schedule I or II (ex: testosterone, butalbital)
• IV – meds or substances with low abuse potential relative to other drugs or those in schedule III (ex: commonly prescribed sleep aids (Ambien, short-acting benzos), relieve anxiety (benzos), control appetite)
• V – meds or substances with low potential for abuse (ex: few meds, select antidiarrheals)

Question 7

What is beneficence?

Answer 7

• To do good

* The healthcare’s obligation to help people in need

Question 8

What is non-maleficence?

Answer 8

• Do no harm
• Requirement that healthcare providers do not harm, whether with or without intention. If harm is unavoidable, the provide must minimize the harm

Question 9

What is autonomy?

Answer 9

• Right of the competent person to choose
• The healthcare provider should support and respect the patient’s ability to make a well-informed decision
• Limitations of autonomy – when that person’s autonomy could interfere with the rights, health, or well-being of another

Question 10

What is justice?

Answer 10

• All people are treated equally

Question 11

What is utilitarianism?

Answer 11

• Allocation of healthcare resources so that the best is done for the greatest number of people

Question 12

What is the most cost effective form of healthcare?

Answer 12

• Primary prevention strategies – aimed at avoiding health problems; can help with cost savings and help actualize the principle of utilitarianism

Question 13

What is veracity?

Answer 13

• To tell the truth
• Provider should be honest and give full disclosure to the patient, abstain from misrepresentation or deception, and report known lapses in standards of care

Question 14

What are the components of informed consent?

Answer 14

• The patient – has capacity or make an informed decision, is able to comprehend the information being presented, and can ask questions
• The provider – must disclose information including benefits and risks and anticipated outcome without therapy

Question 15

When can consent be presumed?

Answer 15

• In limited situations
• In emergency, potentially life-saving situations when the patient is unconscious or incompetent and no surrogate decision-maker is available

Question 16

Who can declare someone as incompetent?

Answer 16

• Only a court can declare a person as incompetent and appoint a guardian to make decisions

Question 17

What is an advanced directive?

Answer 17

• Method of decision-making for patients who cannot communicate their wishes
• Appointed person makes decisions based upon the patient’s past wishes and values

Question 18

What is a healthcare agent (AKA healthcare proxy)?

Answer 18

• A person chosen in advance by an individual to make healthcare decisions in the event the person is unable to do so
• Anyone over 18, regardless of health, should have one
• Usually a spouse is considered the de facto proxy if no other has been appointed
• Long-term non-marital unions are not often recognized

Question 19

What is malpractice?

Answer 19

• The failure of a healthcare pro professional to exercise such care as would a reasonably prudent healthcare professional under the same or similar circumstances

Question 20

What are the components of malpractice?

Answer 20

• Duty – a relationship exists between patient and provider
• Breath of duty – the provider violates accepted standards when rendering care
• Proximate cause – there is an established relationship between the breath and injury
• Damages – damages as a result of the malpractice

Question 21

What is occurrence based liability insurance?

Answer 21

• Policy that covers injuries that occur during the period the policy was active, regardless of whether the policy was renewed or continues to be in effect

Question 22

What is claims-made insurance policy?

Answer 22

• Covers the provider only if the injury occurs within the policy period and if the claim is filed during the time period the policy was in effect – or when an interrupted “tail” insurance policy is in effect

Question 23

What is Medicare part A?

Answer 23

• Hospital services, some post-hospital, some home health, hospice, others

Question 24

What is Medicare part B?

Answer 24

• Supplemental insurance
• Outpatient services, home health
• NPs can be reimbursed under part B as long as services are “physician-like” services, not RN services

Question 25

What is Medicare part C?

Answer 25

• Medicare advantage

* Offered by private companies

Question 26

What is Medicare part D?

Answer 26

• Prescription coverage

* Must have part A and B to qualify

Question 27

What is Medicaid?

Answer 27

• Provides medical benefits to low-income people who don’t have medical insurance or inadequate medical insurance
• Eligibility requirements and type and scope of services are determined by each state

Question 28

General program requirements of Medicaid?

Answer 28

• US citizen with low or very-low income, poverty alone is not a qualifier
• Other enrollee characteristics – blind, disabled, elder in need of nursing home care, pregnant women, have child(ren) with a disability, or be responsible for children under age of 19

Question 29

What are covered entities under HIPAA?

Answer 29

• Healthcare providers, hospitals, labs, health departments
• Health plans (insurance providers)
• Healthcare clearinghouses

Question 30

Which of the following describes the ethical principle of beneficence?
A. The right of the competent person to choose a personal plan of life and action
B. The obligation of the healthcare provider to help people in need
C. The duty of healthcare provider to do no harm
D. The responsibility of the healthcare provider to treat all in the same fair manner

Answer 30

B. The obligation of the healthcare provider to help people in need

Question 31

Which of the following describes the ethical principle of utilitarianism?
A. Healthcare resources are allocated so that the best is done for the greatest number of people
B. The healthcare provider must be truthful and avoid deception
C. The healthcare provider has an obligation to be faithful to commitments made to self and others
D. The responsibility of the healthcare provider is to treat all people in the same fair manner

Answer 31

A. Healthcare resources are allocated so that the best is done for the greatest number of people

Question 32

Which of the following describes the ethical principle of veracity?
A. Healthcare resources are allocated so that the best is done for the greatest number of people
B. The healthcare provider must be truthful and avoid deception
C. The healthcare provider has an obligation to be faithful to commitments made to self and others
D. The responsibility of the healthcare provider is to treat all people in the same fair manner

Answer 32

B. The healthcare provider must be truthful and avoid deception

Question 33

An organization has donated 1000 pediatric vaccines to a community clinic. Ensuring that the distribution of the vaccines is done in a fair and unbiased manner is an example of:
A.	Utilitarianism
B.	Justice 
C.	Beneficence 
D.	Fidelity

Answer 33

B. Justice

Question 34

A mother presents her 3-year-old son with a 2-day history of cough and runny nose without fever. The NP explains that this is likely a viral infection and treatment should focus on symptom management. However, the mother is insistent on getting a prescription for antibiotics despite the NP’s explanation that antibiotics will have limited effectiveness and may cause adverse effects. In this scenario, which of the following best demonstrates the ethical principle of non-maleficence?
A. Providing a prescription for an antibiotic regimen
B. Providing a 2-day sample of antibiotics with a follow-up at 3 days to determine if additional antibiotics are needed
C. Denying a prescription for antibiotics
D. Getting approval from a physician prior to giving the antibiotic prescription

Answer 34

C. Denying a prescription for antibiotics

Question 35

While walking in the parking lot of a grocery store, an NP notices an elderly man fall and hit his head on the ground. The NP quickly rushes over to provide aid to the man. This is an example of:
A.	Beneficence 
B.	Autonomy
C.	Veracity
D.	Utilitarianism

Answer 35

A. Beneficence

Question 36

A patient who underwent CABG following an MI develops a surgical site infection. Upon reviewing the patient’s records, the NP notices that standard antimicrobial prophylaxis was not provided prior to surgery. The ethical principle of (blank) requires the NP to report this finding. 
A.	Non-maleficence
B.	Justice
C.	Veracity
D.	Utilitarianism

Answer 36

C. Veracity

Question 37

A mentally competent patient with advanced cancer is explained 2 treatment options. He decides to take the less invasive technique, despite counseling him that his choice has a lower chance for success. Respecting the patient’s choice demonstrates the ethical principle of:
A.	Justice
B.	Veracity
C.	Paternalism
D.	Autonomy

Answer 37

D. Autonomy

Question 38

A 90-year-old woman with moderate dementia, heart failure, and chronic renal insufficiency presents with a new onset of weakness. Further evaluation reveals a marked hyperkalemia with an eGFR = 22 ml/min/1.73m2. Nephrology recommends hemodialysis. When discussing this option with the patient, she declines this treatment. She also inaccurately reports the current year, location, and name of the USA president. When asked why she does not want dialysis, she states “I do not want to be on a machine. I am quite old and my health is not good.” When asked what she believes will happen if she does not have dialysis, she states, “I guess I will die. That is OK.” In reflecting on this patient, the NP appreciates that:
A. She demonstrates competency in this situation and her wishes can be followed
B. Due to her inability to report accurate date, location, or current president, she is not competent to make healthcare decisions
C. A patient with a documented diagnosis of dementia is considered incompetent to make all healthcare decisions
D. Court-appointed guardianship should be sought

Answer 38

A. She demonstrates competency in this situation and her wishes can be followed

Question 39

Mr. Nelson is a 75-year-old that has been treated unsuccessfully with conservative therapy for bowel obstruction. Documented on his record is his consent to surgery that was obtained by the chief surgical resident. During your preoperative visit with Mr. Nelson, he is alert and relatively comfortable. His wife mentions that her husband had a dose of promethazine (Phenergan) to manage his nausea around the time the surgical consent was obtained. Mrs. Nelson asks, “Is the consent OK since my husband clearly does not feel well?” You respond:
A. Since the chief surgical resident obtained the surgical consent, this should be considered valid
B. Legal council should be obtained prior to proceeding
C. The surgical consent should be obtained from Mrs. Nelson as she is Mr. Nelson’s de facto healthcare proxy
D. You will call the chief surgical resident to clarify the issue of consent

Answer 39

D. You will call the chief surgical resident to clarify the issue of consent

Question 40

Which of the following best demonstrates the intent of informed consent?
A. Discussing the risks of surgery with the parent of a 20-year-old
B. Advising a 48-year-old woman about the likely course of illness if no treatment is rendered
C. Conferring with the husband of a 30-year-old woman who has pneumonia about the benefits of antimicrobial therapy
D. Recommending a course of treatment to a 70-year-old man with prostate cancer

Answer 40

B. Advising a 48-year-old woman about the likely course of illness if no treatment is rendered

Question 41

For an individual to demonstrate capacity to make an informed healthcare decision, all of the following must be present except:
A. The patient has the ability to understand the nature of the clinical condition
B. The patient can interpret the information presented
C. The patient is able to give a reason for the choice if asked
D. The patient does not need to be able to communicate what the care preference is

Answer 41

D. The patient does not need to be able to communicate what the care preference is

Question 42

The adult daughter of an 88-year-old men telephones the nurse practitioner to inquire about her father’s medications. The daughter reports that “my father relies upon me to explain everything to him.” The nurse practitioner’s initial response is to:
A. Ask the daughter to provide a copy of the patient’s advance directed document
B. Assure the daughter that the NP can share the requested information
C. Inform the daughter that she must come to the clinic to discuss her father’s care
D. Tell the daughter that the NP can discuss the information only with the patient

Answer 42

D. Tell the daughter that the NP can discuss the information only with the patient

Question 43

Pull ethnicity out of the question. Does your answer change? A 50-year-old man of Croatian ancestry has a follow-up appointment after cardiac bypass surgery. The patient brings his father with him into the examination room. They are both fluent English speakers. The NP provides culturally sensitive care by the following action.
A. Ask the patient’s father if he has any questions regarding his son’s care
B. Request the patient’s father to leave the room due to confidentiality issues
C. Acknowledge the father’s presence and complete the visit while reporting all findings to the patient
D. Perform the clinical evaluation, then report to the patient’ father the examination findings

Answer 43

C. Acknowledge the father’s presence and complete the visit while reporting all findings to the patient

Question 44

Mr. Miller is a 60-year-old with HTN. On today’s office visit, his BP is noted to be 122/78. The rest of his history and physical exam are unremarkable. He mentions that, in addition to his antihypertensive medication you have prescribed, he uses a teaspoon of hot pepper sauce in a glass of warm water daily to help “clean my blood and lower the pressure. I feel much better when I take it.” Your most appropriate response is to:
A. Advice Mr. Miller to stop using the hot pepper sauce
B. Explore what Mr. Miller means by “clean my blood”
C. Inform Mr. Miller that this practice can result in serious GI complications
D. Ask Mr. Miller to stop the hot pepper sauce use until you can examine the contents of the product he uses

Answer 44

B. Explore what Mr. Miller means by “clean my blood”

Question 45

A 52-year-old woman who is Muslin arrives for an office visit. Her last primary healthcare visit was more than 10 years ago. She mentions that she does not want to disrobe or remove her head cover for a physical exam. You consider that:
A. Her healthcare visit cannot proceed until the patient is able to disrobe for the physical exam
B. A mammogram should be ordered without prior breast exam
C. The option of having a modified physical exam with minimal disrobing should be discussed with the patient
D. The health history can be completed today and the physical exam deferred until a future office visit

Answer 45

C. The option of having a modified physical exam with minimal disrobing should be discussed with the patient

Question 46

You see a 54-year-old woman, Senora Sanchez, who is not fluent in speaking English, who comes into the ED of a 300-bed hospital with a chief complaint of abdominal pain and is accompanied by Tomas, her 10-year-old nephew. Tomas states, “I am here to help my aunt since she doesn’t speak English.” Which of the following is the most appropriate way in conducting this clinical encounter?
A. Direct questions to Tomas, asking him to translate the information to his aunt
B. Direct questions to Senora Sanchez, asking Tomas to translate
C. Advise that Senora Sanchez return with an adult interpreter
D. Call the hospital’s interpreter services department for assistance

Answer 46

D. Call the hospital’s interpreter services department for assistance

Question 47

Which type of professional liability insurance policy covers you only if the injury occurs within the policy period and the claim is filed during the period the policy is in effect?
A.	Claims-made 
B.	Occurrence 
C.	Interval coverage 
D.	Incident petition

Answer 47

A. Claims-made