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 76-year-old woman with presbycusis presents for a follow-up visit on hypertension and dyslipidemia. She's been treated with an ARB, thiazide diuretic, and a statin and is at treatment goal. Which of the following is she most likely to report?
A: Occasional difficulty with speech discrimination.
B: The need to use prescription eyeglasses to read.
C: Altered sense of smell.
D: Diminished sense of touch
The correct answer is A: Occasional difficulty with speech discrimination. Where should you start with this question? First, determine what kind of a question it is. Given that we are being asked to gather additional information about this patient, this is an assessment question. And as we do with all of these, let's first take a look at some background information.
Normative aging results in a variety of changes in the body. This includes changes in the senses, vision, hearing, taste, touch, and smell. Of course, there could be complicating factors in older adults such as select diseases that can result in more significant changes in the senses. For example, you'll notice in practice that nearly everyone over the age of 50 needs glasses, contact lenses, or other vision age aids to help with reading and this age-related change in the vision can be further complicated by the presence of another condition such as cataracts. The sensorineural hearing loss that is normative in a person of advancing age can be complicated and accelerated in a person who's had long-term exposure to significant noise.
This is an important point to keep in mind. And as of course, ear protection is recommended and has been recommended for decades for people who are doing work where there is a lot of noise exposure.
However, not all workers have access to adequate hearing protection and in particular in people of advanced age, they might not have ever been given that advice to protect their hearing. I think of a patient of mine in his nineties who was a carpenter and he used electric saws, drills, noisy things like that. Plus, he was surrounded by coworkers using similar types of equipment, never wore ear protection, hearing protection because it simply wasn't advised.
The result is he does have hearing loss associated with his aging, but it's more profound than one would expect from presbycusis, the age-related hearing loss, alone. In this question, we're presented with an older adult who has some very common chronic health problems and some common meds. And you might be looking at this question and saying something like, ‘Well, does this have anything to do with her hypertension or her dyslipidemia?’
Actually it doesn't. But we're told she has presbycusis, the age-related hearing loss, and how would that affect her life rather than the impact of her chronic diseases? Now, why bother even reviewing a question like this with you? Here is why you might have heard from somebody, maybe more than one, somebody who took the boards who said they got a question that just didn't make any sense and that none the answers seemed to apply.
Well, here we go. We've got one of those questions here because none of the answers here apply directly to her hypertension and dyslipidemia. But there is an option here that potentially applies to her presbycusis. Keep in mind when people tell you that there are questions on the NP boards that “don't make sense" they might be talking about a question like this.
The organizations that offer NP boards are certified by agencies that certify certifying organizations. I know that that sentence doesn't make a whole lot of sense, but in other words, these exams are highly vetted and they're used by nearly every state in the country and the majority of the US territories to determine whether an NP grad will be safe to practice.
In other words, an NP needs to be certified in order to get a license in nearly every state and territory. And what's licensure all about? It's all about ensuring public safety. With that in mind, let's go back and take another look at the question and possible responses. A 76-year-old woman with presbycusis presents for follow-up on hypertension and dyslipidemia treated with an ARB, thiazide diuretic, and a statin, and is at treatment goal.
Which of the following is she most likely to report? A: Occasional difficulty with speech discrimination. This is, of course, the correct answer. As we're told, she has presbycusis, a sensorineural hearing loss associated with aging. Why occasional? Well, quite often people with milder presbycusis, their ability to discriminate the content of speech is largely unchanged if they're in a quiet environment.
They could see the other person's face clearly and there's no or little background noise, what they'll often be bothered by is being in a noisy environment like a restaurant or other public location. So, there's a lot of background noise. And what they'll tell you is they could tell people around them are talking, but they don't understand what they're saying.
Please keep this in mind as well. In the clinical setting, working to see patients with presbycusis in as quiet an environment as possible and that the patient can see your face clearly. Let's take a look at the rest of the option. B: The need to use her prescription eyeglasses to read. This describes presbyopia, the age-related change in vision that starts usually when a person is in their forties and definitely noticeable by the time they're in their fifties.
Vision changes with presbyopia are caused by stiffening of the lenses of the eyes. Usually this is a vision alteration that's easily corrected by eyeglasses, contact lens, sometimes simply by increasing the size of the type that the person is attempting to read. C: Altered sense of smell. The technical term for this is hyposmia and is considered to be a normative age-related change usually starting when a person is in their fifties.
Think of this, we get so much of our pleasure from food by our sense of smell. And this is one reason why you often will hear from older adults that they just don't enjoy certain foods as much as they once did. This mechanism is considered to be part of the aging process in the olfactory system.
D: Diminished sense of touch. Now, this is probably the most underappreciated age-related change in the senses, but it nonetheless is an important consideration. And we tend to think about our vision, our hearing, our sense of taste multiple times a day. At the same time, the diminished sense of touch, not so much something we think about. But this puts older adults at a higher risk for injury and potential falls.
When related to aging, the diminished sense of touch is generally milder and should not be confused with neuropathy. Key takeaway: appreciate that every word in the NP boards posture is there for a reason. Doing this will help you figure out what the question’s purpose is and ultimately the right answer.
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