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.
A 55-year-old woman with recently diagnosed hypertension was started on a standard dose of a thiazide diuretic six weeks ago. Today her blood pressure is 128/78 mm Hg bilaterally, and the patient is feeling well. Her clinical exam fails to reveal abnormal heart sounds or hypertensive retinopathy. The most appropriate action at this time would be to:
Where do you start on a question like this?
First, let's determine what kind of question it is. Given that we were told she was recently diagnosed with hypertension and treated, we're being asked to evaluate response to therapy and advise on whether additional diagnostic testing is needed or whether additional therapy is needed. This is, in fact, an evaluation question.
A few points to consider here: Given a recent hypertensive diagnosis, it appears that a thiazide diuretic has been chosen as her first medication. That's a recommendation found in both JNC8 and the ACC/AHA recommendations, regardless of ethnicity. Blood pressure goal according to ACC/AHA guidelines is recommended to be less than 130/80, which she is. And blood pressure goal, or JNC8, would be less than 140/90, which again, she meets that. In other words, her blood pressure is at treatment goal regardardless of which set of guidelines are being applied
In addition, we're told there's no hypertensive retinopathy or clearly obvious hypertensive-related abnormalities on her cardiac exam. And most importantly, she feels well.
Let's take a look at the therapeutic options we're being given here.
A. Consider switching her high blood pressure medicine to a calcium channel blocker.
Well, she's doing very well on her current regimen, and there's really no need to switch therapy.
We have not been given any compelling indications to do a med switch out from the thiazide diuretic to a calcium channel blocker.
B. Continue on her current medication regimen — This is the correct answer.
Her blood pressure is well controlled, she's tolerating the medication, and she has no evidence of acute hypertensive target organ dysfunction.
C. Add an ACE inhibitor to enhance high blood pressure control.
Well certainly, an ACE inhibitor, or an ARB, or a calcium channel blocker could be added if her blood pressure control is inadequate. Her blood pressure is currently at goal. If in the future her blood pressure is not at goal then one of those meds could possibly be added, but right now it is not needed.
D. Advise the patient to take her high blood pressure medicine for at least one more month prior to evaluating its effectiveness. Both the ACC/AHA and the JNC8 reccomendations include evaluating the effectiveness of high blood pressure medication at 4 weeks post medication initiation, or dose adjustment waiting for two months out, what is not within current best practices.
Key takeaway, in order to answer a question focused on response to therapy, in other words, an evaluation question, you must be familiar with the goals of therapy for commonly encountered conditions such as high blood pressure and the time parameters recommended to meet these goals according to the best evidence.
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