Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer.
So, if you're ready, let's jump right in.
Margaret Fitzgerald: A 49-year-old woman with type 2 diabetes was started on standard dose of an ARB daily 6 weeks ago for management of recently diagnosed hypertension. Today, her BP is at 128/78, stating she's taking the medication without difficulty and is feeling well. The appropriate action at this time would be to:
A: Order a WBC to assess for neutropenia.
B: Continue on her current regimen.
C: Add hydrochlorothiazide to enhance hypotensive control.
D: Obtain a 12-lead ECG.
The correct answer is B: Continue on her current medication regimen. Where should you start? First, determine what kind of a question this is. Given that the patient's been diagnosed with hypertension, treated, and is now here for follow-up, this is an evaluation question. And please keep in mind on the NP boards, the term evaluation is used to describe follow-up.
In other words, the patient has been assessed, diagnosed, treatment, and now you're looking at response to care. A bit of background information: hypertension and type 2 diabetes are climbing comorbidities and are among the top two causes of chronic kidney disease after sclerotic cardiovascular disease. Both conditions contribute to blood vessel damage through a variety of mechanisms, including increased endothelial dysfunction and chronic inflammation.
Dyslipidemia, characterized usually by low HDL, high LDL, and high triglycerides, is often part of the triad seen with hypertension and type 2 diabetes. Treating these three conditions, which are key components of metabolic syndrome, to evidence-based guideline-directed goals, reduces the risk of this dynamic. Given that this question is asking specifically about her blood pressure, and please keep that in mind, I'm only going to limit my comments to that.
You, like, might ask, ‘Why don't you expand on that treating all three conditions?’ And part of this is because I want you to get in the habit of focusing in on exactly what the question asked, rather than thinking about a comorbidity. Of course, in clinical practice, you look at how all three conditions were being managed. Her BP is reported to be 128/78, and that meets the blood pressure goals of the ACC and AHA hypertension guidelines, as well as the ADA guidelines.
These all recommend that the BP be less than 130/80 for people who have hypertension and type 2 diabetes. Her treatment is also consistent with the ADA BP recommendations in that she's getting either an ACE inhibitor or an ARB. This case, she happens to be on an ARB. If in the future hypertension control is inadequate, a second agent like hydrochlorothiazide and/or a calcium channel blocker can be added.
Indeed, I must say, in the majority of people with hypertension and type 2 diabetes, they usually need to be on more than one medication. However, in this question, we're given the scenario of a person who's on a single med and looks like the blood pressure’s under control, we're just going to go ahead and answer what the question is asking.
Let's take a look at the question and the responses. And remember, when we approach an NP board question, you're being asked to demonstrate your clinical reasoning, not what you think might be the right answer, not what you've seen other people do. You're being asked to demonstrate and defend your knowledge base and your clinical reason. In a 49-year-old woman with type 2 diabetes was started on standard dose of an ARB 6 weeks ago with newly diagnosed hypertension.
Today, her BP is 128/78, and she states that she's been taking the medication without difficulty and is feeling well. The appropriate action at this time would be. A: Order WBC to assess neutropenia. This is incorrect. Choosing this option implies that there's a significant risk of neutropenia as a result of ARB use. There is no such risk, nor is there a risk with the ACE inhibitors as well.
B: Continue on her current medication regimen. As mentioned, this is the correct answer. You know, by the way, the recommendation for rechecking BP after the addition or adjustment of a blood pressure medicine, is 4+ weeks. So, in other words, don't recheck the blood pressure sooner than about a month after you've either started a med or adjusted the dose of a medication.
This gives the medication full time to demonstrate its clinical effect in real life. Of course, as I mentioned, you're going to be looking at her overall achievement of treatment goals, including her glucose and lipid control. C: Add hydrochlorothiazide to enhance BP control. Now, this would be a good choice if her blood pressure was not at goal, but right now, it's not needed.
Indeed, it would likely be the next med that I would choose if her blood pressure had been out of recommended range, but that's not what we're seeing here. D: Obtain a 12-lead ECG. An evaluation of a 12-lead looking for dysrhythmias, evidence of heart chamber hypertrophy, and maybe even the findings of cardiac damage in the past is recommended as part of the work-up for a person with new onset hypertension.
So technically, I guess you could look at this as being correct, but it's not the best answer. And so, this question is really focused on what you're going to do next and leaving her at her current medication regimen, given that her BP is at goal, is the best answer. Key takeaway: NP board success hinges on knowing what to do, why you were doing it, and when to do this.
This is the basis of some clinical judgment, and the NP boards are your opportunity to demonstrate that you have and can apply the knowledge base to be a safe, entry level NP.
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