Legal and Ethical Principle in health Care & Quality in Health Care 

(Benchmark Assignment) Applying Decision-Making Models in Health Care.

This is a benchmark assignment.

Choose an ethical decision-making model from among the following three discussed in the lecture and other readings: Nash’s 12 Questions for Moral Choices, Kidder’s Ethical Checkpoints, and Uustal’s Ethical Decision-Making Model. Apply your chosen model to the following ethical dilemma:

Your terminally ill patient told you at her last visit that, since her pain could no longer be completely controlled by any means, and in her opinion she was just waiting to die, she was going to Holland to participate in its physician-assisted suicide program.

What would your advice to this patient be? In a 500-750 word paper, include a letter to your patient offering your insights and recommendations regarding this decision.

In addition, following your letter, include a subsection in which you address the following when completing this assignment:

1. Explain the theory of the chosen ethical      decision-making model as it relates to this scenario. What effect have      this and other models had on medical practice over the years?
2. Should a doctor be able to end the life of an      individual who is suffering and who has no hope of recovery? Why or why      not?
3. How might a living will be used, or not, to guide an      individual’s end of life decisions?
4. How does the use of technology complicate the dying      process?

Include at least three scholarly, peer-reviewed references from the GCU Library to support your positions.

Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

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Criteria for Content

Reflect on the issue of incivility. Think of an experience in which you were directly involved or witnessed incivility in the workplace. Analyze scholarly literature related to the issue of incivility and strategies for cultivating healthful environments.

1.       In a four- to six-page written paper, address the following.

a.       Define and explain the issue of incivility. Use scholarly nursing literature.

b.       Discuss the importance of this issue to nursing. Address the impact of incivility on individuals, microsystem work environments, and the profession of nursing. In this section, use at least three (3) different scholarly nursing literature in-text citations with matching references.  

c.       Provide a scenario (real or fictitious) of incivility in a practice setting. What was the impact on the individuals involved? How was the work environment affected?

d.       Describe three strategies for creating a healthful environment. Use scholarly nursing literature to support each strategy.

e.       Identify your selected specialty track (education, executive, family nurse practitioner, healthcare policy, or nursing informatics). Provide two examples of strategies you will implement in your master’s-prepared advanced practice role to cultivate a healthful work environment.

 

f.        Provide a conclusion. Include a summary on the issue of incivility, strategies to create healthful environments, specialty track, and how you will contribute to cultivating healthful environments in your future professional practice. Include a self-reflection. 

Question 1 1 / 1 point

Severe contact dermatitis caused by poison ivy or poison oak exposure often requires treatment with:

Question options:

Topical antipruritics

Oral corticosteroids for 2 to 3 weeks

Thickly applied topical intermediate-dose corticosteroids

Isolation of the patient to prevent spread of the dermatitis

Question 2 1 / 1 point

Patrick is a 10-year-old patient who presents with uncomfortable constipation. Along with diet changes, a laxative is ordered to provide more rapid relief of constipation. An appropriate choice of medication for a 10-year-old child would be:

Question options:

PEG 3350 (Miralax)

Bisacodyl (Dulcolax) suppository

Docusate (Colace) suppository

Polyethylene glycol electrolyte solution

Question 3 1 / 1 point

Patients who are on chronic long-term proton pump inhibitor therapy require monitoring for:

Question options:

Iron deficiency anemia, vitamin B12 and calcium deficiency

Folate and magnesium deficiency

Elevated uric acid levels leading to gout

Hypokalemia and hypocalcemia

Question 4 1 / 1 point

The drug of choice for treatment of early latent or tertiary syphilis is:

Question options:

Ceftriaxone IM

Benzathine penicillin G IM

Oral azithromycin

Oral ciprofloxacin

Question 5 0 / 1 point

The optimal maximum time frame for HRT or estrogen replacement therapy (ERT) is:

Question options:

2 years

5 years

10 years

15 years

Question 6 1 / 1 point

The Best Pharmaceuticals for Children Act:

Question options:

Includes a pediatric exclusivity rule which extends the patent on drugs studied in children

Establishes a committee that writes guidelines for pediatric prescribing

Provides funding for new drug development aimed at children

Encourages manufacturers specifically to develop pediatric formulations

Question 7 1 / 1 point

Sophie presents to the clinic with a malodorous vaginal discharge and is confirmed to have Trichomonas infection. Treatment for her would include:

Question options:

Metronidazole 2 grams PO x 1 dose

Topical intravaginal metronidazole daily x 7 days

Intravaginal clindamycin daily x 7 days

Azithromycin 2 grams PO x 1 dose

Question 8 1 / 1 point

Jamison has been prescribed citalopram (Celexa) to treat his depression. Education regarding how quickly selective serotonin reuptake inhibitor (SSRI) antidepressants work would be:

Question options:

Appetite and concentration improve in the first 1 to 2 weeks.

Sleep should improve almost immediately upon starting citalopram.

Full response to the SSRI may take 2 to 4 months after he reaches the full therapeutic dose.

His dysphoric mood will improve in 1 to 2 weeks.

Question 9 1 / 1 point

Patients who have a poor metabolism phenotype will have:

Question options:

Slowed metabolism of a prodrug into an active drug, leading to accumulation of Prodrug

Accumulation of inactive metabolites of drugs

A need for increased dosages of medications

Increased elimination of an active drug

Question 10 1 / 1 point

The drug of choice for type 2 diabetics is metformin. Metformin:

Question options:

Decreases glycogenolysis by the liver

Increases the release of insulin from beta cells

Increases intestinal uptake of glucose

Prevents weight gain associated with hyperglycemia

Question 11 1 / 1 point

The first-line therapy for mild-persistent asthma is:

Question options:

High-dose montelukast

Theophylline

Low-dose inhaled corticosteroids

Long-acting beta-2-agonists

Question 12 1 / 1 point

All of the following statements about the Beer’s List are true except:

Question options:

It is a list of medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available.

It is derived from the expert opinion of one geriatrician and is not evidence-based.

These criteria have been adopted by the Centers for Medicare and Medicaid Services for regulation of long-term care facilities.

These criteria are directed at the general population of patients over 65 years of age and do not take disease states into consideration.

Question 13 1 / 1 point

Isosorbide dinitrate is prescribed for a patient with chronic stable angina. This drug is administered twice daily, but the schedule is 7 a.m. and 2 p.m. because:

Question options:

It is a long-acting drug with potential for toxicity.

Nitrate tolerance can develop.

Orthostatic hypotension is a common adverse effect.

It must be taken with milk or food.

Question 14 1 / 1 point

True contraindications to diphtheria, tetanus, and acellular pertussis (DTaP or Tdap) vaccine include:

Question options:

Fever up to 104oF (40.5oC) after previous DTaP vaccine

Family history of seizures after DTaP vaccine

Adolescent pregnancy

Anaphylactic reaction with a previous dose

Question 15 1 / 1 point

Gender differences between men and women in pharmacokinetics include:

Question options:

More rapid gastric emptying so that drugs absorbed in the stomach have less exposure to absorption sites

Higher proportion of body fat so that lipophilic drugs have relatively greater volumes of distribution

Increased levels of bile acids so that drugs metabolized in the intestine have higher concentrations

Slower organ blood flow rates so drugs tend to take longer to be excreted

Question 16 1 / 1 point

Disease states in addition to hypertension in which beta blockade is a compelling indication for the use of beta blockers include:

Question options:

Heart failure

Angina

Myocardial infarction

Dyslipidemia

Question 17 1 / 1 point

Developmental variation in renal function has what impact on prescribing for infants and children?

Question options:

Lower doses of renally excreted drugs may be prescribed to infants younger than age 6 months.

Higher doses of water soluble drugs may need to be prescribed because of increased renal excretion.

Renal excretion rates have no impact on prescribing.

Parents need to be instructed on whether drugs are renally excreted or not.

Question 18 1 / 1 point

When a pharmacoeconomic analysis looks at two or more treatment alternatives that are considered equal in efficacy and compares the costs of each it is referred to as:

Question options:

Cost-minimization analysis

Cost-of-illness analysis

Cost-effectiveness analysis

Cost-benefit analysis

Question 19 1 / 1 point

Allison is an 18-year-old college student with type 1 diabetes. She is on NPH twice daily and Novolog before meals. She usually walks for 40 minutes each evening as part of her exercise regimen. She is beginning a 30-minute swimming class three times a week at 1 p.m. What is important for her to do with this change in routine?

Question options:

Delay eating the midday meal until after the swimming class.

Increase the morning dose of NPH insulin on days of the swimming class.

Adjust the morning insulin injection so that the peak occurs while swimming.

Check glucose level before, during, and after swimming.

Question 20 0 / 1 point

A woman who is pregnant and has hyperthyroidism is best managed by a specialty team who will most likely treat her with:

Question options:

Methimazole

Propylthiouracil (PTU)

Radioactive iodine

Nothing, treatment is best delayed until after her pregnancy ends

Question 21 1 / 1 point

Which of the following is a primary benefit of the use of computerized provider order entry for patient medications?

Question options:

Reduces time that prescribing drugs takes

Eliminates the need to chart drugs prescribed

Decreases prescribing and transcription errors

Helps keep the number of drugs prescribed to a minimum

Question 22 1 / 1 point

Lisa is a healthy nonpregnant adult woman who recently had a urinary tract infection (UTI). She is asking about drinking cranberry juice to prevent a recurrence of the UTI. The correct answer to give her would be:

Question options:

Sixteen ounces per day of cranberry juice cocktail will prevent UTIs.

100% cranberry juice or cranberry juice extract may decrease UTIs in some patients.

There is no evidence that cranberry juice helps prevent UTIs.

Cranberry juice only works to prevent UTIs in children.

Question 23 1 / 1 point

Ginseng, which is taken to assist with memory, may potentiate:

Question options:

Aricept

Insulin

Digoxin

Propranolol

Question 24 1 / 1 point

While on testosterone replacement, hemoglobin and hematocrit levels should be monitored. Levels suggestive of excessive erythrocytosis or abuse are:

Question options:

Hemoglobin 14 g/dl or hematocrit 39%

Hemoglobin 11.5 g/dl or hematocrit 31%

Hemoglobin 13 g/dl or hematocrit 38%

Hemoglobin 17.5 g/dl or hematocrit 54%

Question 25 1 / 1 point

What is the role of calcium supplements when patients take bisphosphonates?

Question options:

They must be restricted to allow the medication to work.

They must be taken in sufficient amounts to provide foundational elements for bone growth.

They must be taken at the same time as the bisphosphonates.

They only work with bisphosphonates if daily intake is restricted.

Question 26 1 / 1 point

Clinical judgment in prescribing includes:

Question options:

Factoring in the cost to the patient of the medication prescribed

Always prescribing the newest medication available for the disease process

Handing out drug samples to poor patients

Prescribing all generic medications to cut costs

Question 27 1 / 1 point

The most cost-effective treatment for two or three impetigo lesions on the face is:

Question options:

Mupirocin ointment

Retapamulin (Altabax) ointment

Topical clindamycin solution

Oral amoxicillin/clavulanate (Augmentin)

Question 28 1 / 1 point

Medications are typically started for angina patients when:

Question options:

The first permanent EKG changes occur

The start of class I or II symptoms

The events trigger a trip to the emergency department

When troponin levels become altered

Question 29 0 / 1 point

Rabi is being prescribed phenytoin for seizures. Monitoring includes assessing:

Question options:

For phenytoin hypersensitivity syndrome 3 to 8 weeks after starting treatment

For pedal edema throughout therapy

Heart rate at each visit and consider altering therapy if heart rate is less than 60 bpm

For vision changes, such as red-green blindness, at least annually

Question 30 1 / 1 point

Alterations in drug metabolism among Asians may lead to:

Question options:

Slower metabolism of antidepressants, requiring lower doses

Faster metabolism of neuroleptics, requiring higher doses

Altered metabolism of omeprazole, requiring higher doses

Slower metabolism of alcohol, requiring higher doses

Question 31 1 / 1 point

The dosage of Vitamin B12 to initially treat pernicious anemia is:

Question options:

Nasal cyanocobalamin 1 gram spray in each nostril daily x 1 week then weekly x 1 month

Vitamin B12 IM monthly

Vitamin B12 1,000 mcg IM daily x 1 week then 1,000 mg IM weekly for a month

Oral cobalamin 1,000 mcg daily

Question 32 1 / 1 point

There is often cross-sensitivity and cross-resistance between penicillins and cephalosporins because:

Question options:

Renal excretion is similar in both classes of drugs.

When these drug classes are metabolized in the liver they both produce resistant enzymes.

Both drug classes contain a beta-lactam ring that is vulnerable to beta-lactamase-producing organisms.

There is not an issue with cross-resistance between the penicillins and cephalosporins.

Question 33 1 / 1 point

The reason that two MMR vaccines at least a month apart are recommended is:

Question options:

The second dose of MMR “boosts” the immunity built from the first dose.

Two vaccines 1 month apart is the standard dosing for all live virus vaccines.

If the two MMR vaccine doses are given too close together there is a greater likelihood of severe localized reaction to the vaccine.

Only 95% of patients are fully immunized for measles after the first vaccine, with 99% having immunity after two doses of MMR.

Question 34 1 / 1 point

A laboratory result indicates that the peak level for a drug is above the minimum toxic concentration. This means that the:

Question options:

Concentration will produce therapeutic effects

Concentration will produce an adverse response

Time between doses must be shortened

Duration of action of the drug is too long

Question 35 1 / 1 point

Why is the consistency of taking paroxetine (Paxil) and never running out of medication more important than with most other selective serotonin reuptake inhibitors (SSRIs)?

Question options:

It has a shorter half-life and withdrawal syndrome has a faster onset without taper.

It has the longest half-life and the withdrawal syndrome has a faster onset.

It is quasi-addictive in the dopaminergic reward system.

It is the most activating of SSRI medications and will cause the person to have sudden deep sadness.

Question 36 1 / 1 point

Chee is a 15-month-old male whose screening hemoglobin is 10.4 g/dL. Treatment for his anemia would be:

Question options:

18 mg/day of iron supplementation

6 mg/kg per day of elemental iron

325 mg ferrous sulfate per day

325 mg ferrous sulfate tid

Question 37 1 / 1 point

Education for patients who use an inhaled beta-agonist and an inhaled corticosteroid includes:

Question options:

Use the inhaled corticosteroid first, followed by the inhaled beta-agonists.

Use the inhaled beta-agonist first, followed by the inhaled corticosteroid.

Increase fluid intake to 3 liters per day.

Avoid use of aspirin or ibuprofen while using inhaled medications.

Question 38 1 / 1 point

According to the U.S. Office of Minority Health, poor health outcomes among African Americans are attributed to:

Question options:

The belief among African Americans that prayer is more powerful than drugs

Poor compliance on the part of the African American patient

The genetic predisposition for illness found among African Americans

Discrimination, cultural barriers, and lack of access to health care

Question 39 0 / 1 point

Precautions that should be taken when prescribing controlled substances include:

Question options:

Faxing the prescription for a Schedule II drug directly to the pharmacy

Using tamper-proof paper for all prescriptions written for controlled drugs

Keeping any pre-signed prescription pads in a locked drawer in the clinic

Using only numbers to indicate the amount of drug to be prescribed

Question 40 1 / 1 point

When considering which cholesterol-lowering drug to prescribe, which factor determines the type and intensity of treatment?

Question options:

Total LDL

Fasting HDL

Coronary artery disease risk level

Fasting total cholesterol

Question 41 1 / 1 point

Which of the following patients may be treated with a 3-day course of therapy for their urinary tract infection?

Question options:

Juanita, a 28-year-old pregnant woman

Sally, a 16-year-old healthy adolescent

Jamie, a 24-year-old female

Suzie, a 26-year-old diabetic

Question 42 1 / 1 point

If an adult patient with comorbidities cannot reliably take oral antibiotics to treat pneumonia, an appropriate initial treatment option would be:

Question options:

IV or IM gentamicin

IV or IM ceftriaxone

IV amoxicillin

IV ciprofloxacin

Question 43 1 / 1 point

Varenicline (Chantix) may be prescribed for tobacco cessation. Instructions to the patient who is starting varenicline include:

Question options:

The maximum time varenicline can be used is 12 weeks.

Nausea is a sign of varenicline toxicity and should be reported to the provider.

The starting regimen for varenicline is start taking 1 mg twice a day a week before the quit date.

Neuropsychiatric symptoms may occur.

Question 44 0 / 1 point

Harold, a 42-year-old African American, has moderate persistent asthma. Which of the following asthma medications should be used cautiously, if at all?

Question options:

Betamethasone, an inhaled corticosteroid

Salmeterol, an inhaled long-acting beta-agonist

Albuterol, a short-acting beta-agonist

Montelukast, a leukotriene modifier

Question 45 1 / 1 point

Absolute contraindications that clinicians must consider when initiating estrogen therapy include:

Question options:

Undiagnosed dysfunctional uterine bleeding

Deep vein or arterial thromboemboli within the prior year

Endometriosis

Both a. and b.

All of the above

Question 46 1 / 1 point

Several classes of drugs have interactions with cholinergic blockers. Which of the following is true about these interactions?

Question options:

Drugs with a narrow therapeutic range given orally may not stay in the GI tract long enough to produce an action.

Additive antimuscarinic effects may occur with antihistamines.

Cholinergic blockers may decrease the sedative effects of hypnotics.

Cholinergic blockers are contraindicated with antipsychotics.

Question 47 1 / 1 point

Leonard is completing a 6-month regimen to treat tuberculosis (TB). Monitoring of a patient on TB therapy includes:

Question options:

Monthly sputum cultures

Monthly chest x-ray

Bronchoscopy every 3 months

All of the above

Question 48 1 / 1 point

The action of “gliptins” is different from other antidiabetic agents because they:

Question options:

Have a low risk for hypoglycemia

Are not associated with weight gain

Close ATP-dependent potassium channels in the beta cell

Act on the incretin system to indirectly increase insulin production

Question 49 1 / 1 point

Laboratory values are actually different for TSH when screening for thyroid issues and when used for medication management. Which of the follow holds true?

Question options:

Screening TSH has a wider range of normal values 0.02-5.0; therapeutic levels need to remain above 5.0.

Screening values are much narrower than the acceptable range used to keep a person stable on hormone replacement.

Therapeutic values are kept between 0.05 and 3.0 ideally. Screening values are considered acceptable up to 10.

Screening values are between 5 and 10, and therapeutic values are greater than 10.

Question 50 1 / 1 point

Azithromycin dosing requires that the first day’s dosage be twice those of the other 4 days of the prescription. This is considered a loading dose. A loading dose:

Question options:

Rapidly achieves drug levels in the therapeutic range

Requires four- to five-half-lives to attain

Is influenced by renal function

Is directly related to the drug circulating to the target tissues

Question 51 1 / 1 point

Conjunctivitis in a child that is accompanied by acute otitis media is treated with:

Question options:

Sulfacetamide 10% ophthalmic solution (Bleph-10)

Bacitracin/polymyxin B (Polysporin) ophthalmic drops

Ciprofloxacin (Ciloxan) ophthalmic drops

High-dose oral amoxicillin

Question 52 1 / 1 point

To improve actual effectiveness of oral contraceptives women should be educated regarding:

Question options:

Use of a back-up method if they have vomiting or diarrhea during a pill packet

Doubling pills if they have diarrhea during the middle of a pill pack

The fact that they will have a normal menstrual cycle if they miss two pills

The fact that mid-cycle spotting is not normal and the provider should be contacted immediately

Question 53 1 / 1 point

An acceptable first-line treatment for peptic ulcer disease with positive H. pylori test is:

Question options:

Histamine2 receptor antagonists for 4 to 8 weeks

Proton pump inhibitor bid for 12 weeks until healing is complete

Proton pump inhibitor bid plus clarithromycin plus amoxicillin for 14 days

Proton pump inhibitor bid and levofloxacin for 14 days

Question 54 1 / 1 point

Larry is taking allopurinol to prevent gout. Monitoring of a patient who is taking allopurinol includes:

Question options:

Complete blood count

Blood glucose

C-reactive protein

BUN, creatinine, and creatinine clearance

Question 55 1 / 1 point

When discussing with a patient the different start methods used for oral combined contraceptives, the advantage of a Sunday start over the other start methods is:

Question options:

Immediate protection against pregnancy the first week of using the pill

No back-up method is needed when starting

Menses occur during the week

They can start the pill on the Sunday after the office visit

Question 56 1 / 1 point

Sadie is a 90-year-old patient who requires a new prescription. What changes in drug distribution with aging would influence prescribing for Sadie?

Question options:

Increased volume of distribution

Decreased lipid solubility

Decreased plasma proteins

Increased muscle-to-fat ratio

Question 57 1 / 1 point

Rose is a 3-year-old patient with an upper respiratory infection (URI). Treatment for her URI would include:

Question options:

Amoxicillin

Diphenhydramine

Pseudoephedrine

Nasal saline spray

Question 58 1 / 1 point

Instructions for the use of nicotine gum include:

Question options:

Chew the gum quickly to get a peak effect.

The gum should be “parked” in the buccal space between chewing.

Acidic drinks such as coffee help with the absorption of the nicotine.

The highest abstinence rates occur if the patient chews the gum when he or she is having cravings.

Question 59 0 / 1 point

Howard is a 72-year-old male who occasionally takes diphenhydramine for his seasonal allergies. Monitoring for this patient taking diphenhydramine would include assessing for:

Question options:

Urinary retention

Cardiac output

Peripheral edema

Skin rash

Question 60 0 / 1 point

Vicky, age 56 years, comes to the clinic requesting a refill of her Fiorinal (aspirin and butalbital) that she takes for migraines. She has been taking this medication for over 2 years for migraines and states one dose usually works to abort her migraine. What is the best care for her?

Question options:

Switch her to sumatriptan (Imitrex) to treat her migraines.

Assess how often she is using Fiorinal and refill her medication.

Switch her to a beta blocker such as propranolol to prevent her migraine.

Request she return to the original prescriber of Fiorinal as you do not prescribe butalbital for migraines.

Question 61 1 / 1 point

Drugs that have a significant first-pass effect:

Question options:

Must be given by the enteral (oral) route only

Bypass the hepatic circulation

Are rapidly metabolized by the liver and may have little if any desired action

Are converted by the liver to more active and fat-soluble forms

Question 62 1 / 1 point

First-line therapy for treating topical fungal infections such as tinea corporis (ringworm) or tinea pedis (athlete’s foot) would be:

Question options:

OTC topical azole (clotrimazole, miconazole)

Oral terbinafine

Oral griseofulvin microsize

Nystatin cream or ointment

Question 63 1 / 1 point

A client asks the NP about the differences in drug effects between men and women. What is known about the differences between the pharmacokinetics of men and women?

Question options:

Body temperature varies between men and women.

Muscle mass is greater in women.

Percentage of fat differs between genders.

Proven subjective factors exist between the genders.

Question 64 1 / 1 point

Opiates are used mainly to treat moderate to severe pain. Which of the following is NOT true about these drugs?

Question options:

All opiates are scheduled drugs which require a DEA license to prescribe.

Opiates stimulate only mu receptors for the control of pain.

Most of the adverse effects of opiates are related to mu receptor stimulation.

Naloxone is an antagonist to opiates.

Question 65 1 / 1 point

A potentially life-threatening adverse response to angiotensin-converting enzyme inhibitors is angioedema. Which of the following statements is true about this adverse response?

Question options:

Swelling of the tongue or hoarseness are the most common symptoms.

It appears to be related to the decrease in aldosterone production.

Presence of a dry, hacky cough indicates a high risk for this adverse response.

Because it takes time to build up a blood level, it occurs after being on the drug for about 1 week.

Question 66 1 / 1 point

The benefits to the patient of having an Advanced Practice Registered Nurse (APRN) prescriber include:

Question options:

Nurses know more about Pharmacology than other prescribers because they take it both in their basic nursing program and in their APRN program.

Nurses care for the patient from a holistic approach and include the patient in decision making regarding their care.

APRNs are less likely to prescribe narcotics and other controlled substances.

APRNs are able to prescribe independently in all states, whereas a physician’s assistant needs to have a physician supervising their practice.

Question 67 1 / 1 point

Education of women who are being treated with ophthalmic antibiotics for conjunctivitis includes:

Question options:

Throwing away eye makeup and purchasing new

Redness and intense burning is normal with ophthalmic antibiotics

When applying eye ointment, set the tip of the tube on the lower lid and squeeze in inch

Use a cotton swab to apply ointment, spreading the ointment all over the lid and in the conjunctival sac

Question 68 1 / 1 point

When determining drug treatment the NP prescriber should:

Question options:

Always use evidence-based guidelines

Individualize the drug choice for the specific patient

Rely on his or her experience when prescribing for complex patients

Use the newest drug on the market for the condition being treated

Question 69 1 / 1 point

Class I recommendations for stage A heart failure include:

Question options:

Aerobic exercise within tolerance levels to prevent the development of heart failure

Reduction of sodium intake to less than 2,000 mg/day to prevent fluid retention

Beta blockers for all patients regardless of cardiac history

Treatment of thyroid disorders, especially if they are associated with Tachyarrhythmias

Question 70 1 / 1 point

Male patients who should not be prescribed phosphodiesterase type 5 (PDE-5) inhibitors include:

Question options:

Diabetics

Those who have had an acute myocardial infarction in the past 6 months

Patients who are deaf

Patients under age 60 years of age

Question 71 1 / 1 point

The first-line drug choice for a previously healthy adult patient diagnosed with community-acquired pneumonia would be:

Question options:

Ciprofloxacin

Azithromycin

Amoxicillin

Doxycycline

Question 72 1 / 1 point

If a patient with symptoms of gastroesophageal reflux disease states that he has been self-treating at home with OTC ranitidine daily, the appropriate treatment would be:

Question options:

Prokinetic (metoclopramide) for 4 to 8 weeks

Proton pump inhibitor (omeprazole) for 12 weeks

Histamine2 receptor antagonist (ranitidine) for 4 to 8 weeks

Cytoprotective drug (misoprostol) for 2 weeks

Question 73 1 / 1 point

Patients who are prescribed exogenous androgens need to be warned that decreased libido:

Question options:

Is an unusual side effect of androgens and should be reported to the provider

Is treated with increased doses of androgens, so the patient should let the provider know if he is having problems

May be a sign of early prostate cancer and he should make an appointment for a prostate screening exam

May occur with androgen therapy

Question 74 1 / 1 point

Which diuretic agents typically do not need potassium supplementation?

Question options:

The loop diuretics

The thiazide diuretics

The aldosterone inhibitors

They all need supplementation

Question 75 0 / 1 point

Jim is being treated for hypertension. Because he has a history of heart attack, the drug chosen is atenolol. Beta blockers treat hypertension by:

Question options:

Increasing heart rate to improve cardiac output

Reducing vascular smooth muscle tone

Increasing aldosterone-mediated volume activity

Reducing aqueous humor production

Question 76 1 / 1 point

Patient education regarding taking iron replacements includes:

Question options:

Doubling the dose if they miss a dose to maintain therapeutic levels

Taking the iron with milk or crackers if it upsets their stomach

Iron is best taken on an empty stomach with juice

Antacids such as Tums may help the upset stomach caused by iron therapy

Question 77 1 / 1 point

Patient education for a patient who is prescribed antibiotics for sinusitis includes:

Question options:

Use of nasal saline washes

Use of inhaled corticosteroids

Avoiding the use of ibuprofen while ill

Use of laxatives to treat constipation

Question 78 1 / 1 point

Patients who are treated with greater than 100 grams per week of topical calcipotriene for psoriasis need to be monitored for:

Question options:

High vitamin D levels

Hyperkalemia

Hypercalcemia

Hyperuricemia

Question 79 1 / 1 point

Sook has been prescribed gabapentin to treat neuropathic pain and is complaining of feeling depressed and having “strange” thoughts. The appropriate initial action would be:

Question options:

Increase her dose

Assess for suicidal ideation

Discontinue the medication immediately

Decrease her dose to half then slowly titrate up the dose

Question 80 1 / 1 point

Nonadherence is especially common in drugs that treat asymptomatic conditions, such as hypertension. One way to reduce the likelihood of nonadherence to these drugs is to prescribe a drug that:

Question options:

Has a short half-life so that missing one dose has limited effect

Requires several dosage titrations so that missed doses can be replaced with lower doses to keep costs down

Has a tolerability profile with fewer of the adverse effects that are considered “irritating,” such as nausea and dizziness

Must be taken no more than twice a day

Question 81 1 / 1 point

Which the following persons should not have a statin medication ordered?

Question options:

Someone with 3 first- or second-degree family members with history of muscle issues when started on statins

Someone with high lipids, but low BMI

Premenopausal woman with recent history of hysterectomy

Prediabetic male with known metabolic syndrome

Question 82 1 / 1 point

The Combat Methamphetamine Epidemic Act, which is part of the 2006 U.S. Patriot Act:

Question options:

Requires all providers to screen their patients for methamphetamine use

Restricts the prescribing of amphetamines to U.S. citizens

Requires a prescription be written for all methamphetamine precursors in all states

Restricts the sales of drugs that contain methamphetamine precursors, including a daily and 30-day limit on sales

Question 83 0 / 1 point

Monitoring for patients who are on long-term antifungal therapy with ketoconazole includes:

Question options:

Platelet count

BUN and creatinine

White blood cell count

AST, ALT, alkaline phosphatase, and bilirubin

Question 84 0 / 1 point

Which of the following holds true for the pharmacokinetics of women?

Question options:

Gastric emptying is faster than that of men.

Organ blood flow is the same as that of men.

Evidence is strong concerning renal differences in elimination.

Medications that involve binding globulins are impacted by estrogen levels.

Question 85 0 / 1 point

Henry is 82 years old and takes two aspirin every morning to treat the arthritis pain in his back. He states the aspirin helps him to “get going” each day. Lately he has had some heartburn from the aspirin. After ruling out an acute GI bleed, what would be an appropriate course of treatment for Henry?

Question options:

Add an H2 blocker such as ranitidine to his therapy.

Discontinue the aspirin and switch him to Vicodin for the pain.

Decrease the aspirin dose to one tablet daily.

Have Henry take an antacid 15 minutes before taking the aspirin each day.

Question 86 1 / 1 point

When prescribing a tetracycline or quinolone antibiotic it is critical to instruct the patient:

Question options:

Not to take their regularly prescribed medications while on these antibiotics

Regarding the need for lots of acidic foods and juices, such as orange juice, to enhance absorption

Not to take antacids while on these medications, as the antacid decreases absorption

That there are no drug interactions with these antibiotics

Question 87 1 / 1 point

A provider may consider testing for CYP2D6 variants prior to starting tamoxifen for breast cancer to:

Question options:

Ensure the patient will not have increased adverse drug reactions to the tamoxifen

Identify potential drug-drug interactions that may occur with tamoxifen

Reduce the likelihood of therapeutic failure with tamoxifen treatment

Identify poor metabolizers of tamoxifen

Question 88 1 / 1 point

IV forms of bisphosphonates are used for all the following except:

Question options:

Severe gastric irritation with oral forms

Known cancer mets into the bone

Persons with advancing renal dysfunction

Progression of bone loss on oral formulations

Question 89 1 / 1 point

The New York Heart Association and the Canadian Cardiovascular Society have described grading criteria for levels of angina. Angina that occurs with unusually strenuous activity or on walking or climbing stair after meals is class:

Question options:

I

II

III

IV

Question 90 1 / 1 point

ACE inhibitors are contraindicated in pregnancy. While treatment of heart failure during pregnancy is best done by a specialist, which of the following drug classes is considered to be safe, at least in the later parts of pregnancy?

Question options:

Diuretics

ARBs

Beta blockers

Nitrates

Question 91 1 / 1 point

Pharmacoeconomics is:

Question options:

The study of the part of the U.S. economy devoted to drug use

The study of the impact of prescription drug costs on the overall economy

The analysis of the costs and consequences of any health-care-related treatment or service

The analysis of the clinical efficacy of the drug

Question 92 1 / 1 point

Goals when treating tuberculosis include:

Question options:

Completion of recommended therapy

Negative purified protein derivative at the end of therapy

Completely normal chest x-ray

All of the above

Question 93 1 / 1 point

Elena Vasquez’s primary language is Spanish, and she speaks very limited English. Which technique would be appropriate to use in teaching her about a new drug you have just prescribed?

Question options:

Use correct medical terminology because Spanish has a Latin base.

Use a family member who speaks more English to act as an interpreter.

Use a professional interpreter or a reliable staff member who can act as an interpreter.

Use careful, detailed explanations.

Question 94 1 / 1 point

Which of the following statements is true about acute pain?

Question options:

Somatic pain comes from body surfaces and is only sharp and well-localized.

Visceral pain comes from the internal organs and is most responsive to acetaminophen and opiates.

Referred pain is present in a distant site for the pain source and is based on activation of the same spinal segment as the actual pain site.

Acute neuropathic pain is caused by lack of blood supply to the nerves in a given area.

Question 95 1 / 1 point

The role of the NP in the use of herbal medication is to:

Question options:

Maintain competence in the prescribing of common herbal remedies

Recommend common over-the-counter herbs to patients

Educate patients and guide them to appropriate sources of care

Encourage patients to not use herbal therapy due to the documented dangers

Question 96 1 / 1 point

Being competent in the use of information technology in clinical practice is expected in professional nurses. Advanced practice competence includes the ability to:

Question options:

Search for information using the most common search engines

Serve as content experts in developing, implementing, and evaluating information Systems

Write programs to assure the integrity of health information

Use information technology to prescribe drugs

Question 97 0 / 1 point

Sally has been prescribed aspirin 320 mg per day for her atrial fibrillation. She also takes aspirin four or more times a day for arthritis pain.What are the symptoms of aspirin toxicity for which she would  need to be evaluated?

Question options:

Tinnitus

Diarrhea

Hearing loss

Photosensitivity

Question 98 1 / 1 point

Nurse practitioner prescriptive authority is regulated by:

Question options:

The National Council of State Boards of Nursing

The U.S. Drug Enforcement Administration

The State Board of Nursing for each state

The State Board of Pharmacy

Question 99 1 / 1 point

An Investigational New Drug is filed with the U.S. Food and Drug Administration:

Question options:

When the manufacturer has completed phase III trials

When a new drug is discovered

Prior to animal testing of any new drug entity

Prior to human testing of any new drug entity

Question 100 1 / 1 point

Preventative therapy for cluster headaches includes:

Question options:

Massage or relaxation therapy

Ergotamine nightly before bed

Intranasal lidocaine four times a day during “clusters” of headaches

Propranolol (Inderal) daily

 

 

  

Groups 1 and 3 will present Case 1 on 09/20/2018. All groups will be required to turn in a position brief. For the position brief, please answer the nine questions listed below. Please include the questions with the brief. When answering the questions, please ensure to use all information given to the class as a reference. For the questions requiring external research, please ensure to cite the information.  The group presentation should be between 20-25 minutes. The presenting group will be required to provide at least four PowerPoint slides. One set of slides are to be given to the professor and the other three are to be distributed among the other groups. When presenting, business casual attire will be required. Non-business casual attire will result in a reduction of points. Please have the group leader submit an electronic copy of the brief [as a word document (.doc/.docx)] and (when applicable) the PowerPoint slides under the Tests and Quizzes section on blackboard by 11:59 PM Monday (09/24/2018).

1: Please provide a detailed summary of the case. Please ensure to include and discuss all relevant material .

2: Please discuss at least four challenges facing inner city urban hospitals today (external research from respectable sources is required to answer this question) .

3: Please discuss the policy associated with the formation of 501C3 hospitals and the rationale associated with their existence. In addition, please discuss the community benefit obligations under the PPACA and how it may relate to Summit Regional Hospital (external research from respectable sources are required to answer this question) .

4: Please discuss the concept of population health management and what is needed to succeed in this environment (external research from respectable sources are required to answer this question) .

5: Please perform a SWOT (strengths, weaknesses, opportunities and threats) analysis on Summit Regional. Identify and explain at least four points for each category (please ensure to use information provided in the case to support your answer) .

6:  Please illustrate and discuss all of the steps in the Evidence Based Management (EBM) model to analyze three overall problems and arrive at three specific evidence based solutions.  Please analyze the solutions separately and use a table/chart to organize/explain the points in the mode and also ensure to use information provided in the case to support your answer . 

7: Please rank and explain the three evidence based solutions from most likely to implement to least likely to implement .

8: Please specifically identify how your group will implement the chosen solution and then identify how you will evaluate the effectiveness (impact) of the solution . 

9: Please identify at least three examples of courses (taken during the HCA program), which were most applicable in helping to apply the material in the case. Please ensure to explain why these courses were chosen .

The requirements for this essay are:

1. 500-600 words; 5-paragraph structure (can have more than five). 

2. Your idea about the story itself—the value of the story (at least a paragraph)

3. How it applies to life in general (at least a paragraph)

4. How it applies to you.  Write about an item that is important to you, one that has been passed down to you or one that you hope will be or an item that you have that you will plan to pass down to someone (at least a paragraph). .

5. Be sure to supply

    a. A parenthetical reference

    b. A Works Cited

I will wait for her in the yard that Maggie and I made so clean and wavy yesterday afternoon. A yard like this is more comfortable than most people know. It is not just a yard. It is like an extended living room. When the hard clay is swept clean as a floor and the fine sand around the edges lined with tiny, irregular grooves, anyone can come and sit and look up into the elm tree and wait for the breezes that never come inside the house.

Maggie will be nervous until after her sister goes: she will stand hopelessly in corners, homely and ashamed of the burn scars down her arms and legs, eying her sister with a mixture of envy and awe. She thinks her sister has held life always in the palm of one hand, that “no” is a word the world never learned to say to her.

You’ve no doubt seen those TV shows where the child who has “made it” is confronted, as a surprise, by her own mother and father, tottering in weakly from backstage. (A pleasant surprise, of course: What would they do if parent and child came on the show only to curse out and insult each other?) On TV mother and child embrace and smile into each other’s faces. Sometimes the mother and father weep, the child wraps them in her arms and leans across the table to tell how she would not have made it without their help. I have seen these programs.

Sometimes I dream a dream in which Dee and I are suddenly brought together on a TV program of this sort. Out of a dark and soft.seated limousine I am ushered into a bright room filled with many people. There I meet a smiling, gray, sporty man like Johnny Carson who shakes my hand and tells me what a fine girl I have. Then we are on the stage and Dee is embracing me with tears in her eyes. She pins on my dress a large orchid, even though she has told me once that she thinks orchids are tacky flowers.

In real life I am a large, big.boned woman with rough, man.working hands. In the winter I wear flannel nightgowns to bed and overalls dur.ing the day. I can kill and clean a hog as mercilessly as a man. My fat keeps me hot in zero weather. I can work outside all day, breaking ice to get water for washing; I can eat pork liver cooked over the open fire minutes after it comes steaming from the hog. One winter I knocked a bull calf straight in the brain between the eyes with a sledge hammer and had the meat hung up to chill before nightfall. But of course all this does not show on television. I am the way my daughter would want me to be: a hundred pounds lighter, my skin like an uncooked barley pancake. My hair glistens in the hot bright lights. Johnny Carson has much to do to keep up with my quick and witty tongue.

But that is a mistake. I know even before I wake up. Who ever knew a Johnson with a quick tongue? Who can even imagine me looking a strange white man in the eye? It seems to me I have talked to them always with one foot raised in flight, with my head fumed in whichever way is farthest from them. Dee, though. She would always look anyone in the eye. Hesitation was no part of her nature.

“How do I look, Mama?” Maggie says, showing just enough of her thin body enveloped in pink skirt and red blouse for me to know she’s there, almost hidden by the door.

“Come out into the yard,” I say.

Have you ever seen a lame animal, perhaps a dog run over by some careless person rich enough to own a car, sidle up to someone who is ignorant enough to be kind to him? That is the way my Maggie walks. She has been like this, chin on chest, eyes on ground, feet in shuffle, ever since the fire that burned the other house to the ground.

Dee is lighter than Maggie, with nicer hair and a fuller figure. She’s a woman now, though sometimes I forget. How long ago was it that the other house burned? Ten, twelve years? Sometimes I can still hear the flames and feel Maggie’s arms sticking to me, her hair smoking and her dress falling off her in little black papery flakes. Her eyes seemed stretched open, blazed open by the flames reflected in them. And Dee. I see her standing off under the sweet gum tree she used to dig gum out of; a look of concentration on her face as she watched the last dingy gray board of the house fall in toward the red.hot brick chimney. Why don’t you do a dance around the ashes? I’d wanted to ask her. She had hated the house that much.

I used to think she hated Maggie, too. But that was before we raised money, the church and me, to send her to Augusta to school. She used to read to us without pity; forcing words, lies, other folks’ habits, whole lives upon us two, sitting trapped and ignorant underneath her voice. She washed us in a river of make.believe, burned us with a lot of knowl edge we didn’t necessarily need to know. Pressed us to her with the serf’ ous way she read, to shove us away at just the moment, like dimwits, we seemed about to understand.

Dee wanted nice things. A yellow organdy dress to wear to her grad.uation from high school; black pumps to match a green suit she’d made from an old suit somebody gave me. She was determined to stare down any disaster in her efforts. Her eyelids would not flicker for minutes at a time. Often I fought off the temptation to shake her. At sixteen she had a style of her own: and knew what style was.

I never had an education myself. After second grade the school was closed down. Don’t ask my why: in 1927 colored asked fewer questions than they do now. Sometimes Maggie reads to me. She stumbles along good.naturedly but can’t see well. She knows she is not bright. Like good looks and money, quickness passes her by. She will marry John Thomas (who has mossy teeth in an earnest face) and then I’ll be free to sit here and I guess just sing church songs to myself. Although I never was a good singer. Never could carry a tune. I was always better at a man’s job. I used to love to milk till I was hooked in the side in ’49. Cows are soothing and slow and don’t bother you, unless you try to milk them the wrong way.

I have deliberately turned my back on the house. It is three rooms, just like the one that burned, except the roof is tin; they don’t make shingle roofs any more. There are no real windows, just some holes cut in the sides, like the portholes in a ship, but not round and not square, with rawhide holding the shutters up on the outside. This house is in a pasture, too, like the other one. No doubt when Dee sees it she will want to tear it down. She wrote me once that no matter where we “choose” to live, she will manage to come see us. But she will never bring her friends. Maggie and I thought about this and Maggie asked me, “Mama, when did Dee ever have any friends?”

She had a few. Furtive boys in pink shirts hanging about on washday after school. Nervous girls who never laughed. Impressed with her they worshiped the well.turned phrase, the cute shape, the scalding humor that erupted like bubbles in Iye. She read to them.

When she was courting Jimmy T she didn’t have much time to pay to us, but turned all her faultfinding power on him. He flew to marry a cheap city girl from a family of ignorant flashy people. She hardly had time to recompose herself.

When she comes I will meet—but there they are!

Maggie attempts to make a dash for the house, in her shuffling way, but I stay her with my hand. “Come back here, ” I say. And she stops and tries to dig a well in the sand with her toe.

It is hard to see them clearly through the strong sun. But even the first glimpse of leg out of the car tells me it is Dee. Her feet were always neat.looking, as if God himself had shaped them with a certain style. From the other side of the car comes a short, stocky man. Hair is all over his head a foot long and hanging from his chin like a kinky mule tail. I hear Maggie suck in her breath. “Uhnnnh, ” is what it sounds like. Like when you see the wriggling end of a snake just in front of your foot on the road. “Uhnnnh.”

Dee next. A dress down to the ground, in this hot weather. A dress so loud it hurts my eyes. There are yellows and oranges enough to throw back the light of the sun. I feel my whole face warming from the heat waves it throws out. Earrings gold, too, and hanging down to her shoul.ders. Bracelets dangling and making noises when she moves her arm up to shake the folds of the dress out of her armpits. The dress is loose and flows, and as she walks closer, I like it. I hear Maggie go “Uhnnnh” again. It is her sister’s hair. It stands straight up like the wool on a sheep. It is black as night and around the edges are two long pigtails that rope about like small lizards disappearing behind her ears.

“Wa.su.zo.Tean.o!” she says, coming on in that gliding way the dress makes her move. The short stocky fellow with the hair to his navel is all grinning and he follows up with “Asalamalakim, my mother and sister!” He moves to hug Maggie but she falls back, right up against the back of my chair. I feel her trembling there and when I look up I see the perspiration falling off her chin.

“Don’t get up,” says Dee. Since I am stout it takes something of a push. You can see me trying to move a second or two before I make it. She turns, showing white heels through her sandals, and goes back to the car. Out she peeks next with a Polaroid. She stoops down quickly and lines up picture after picture of me sitting there in front of the house with Maggie cowering behind me. She never takes a shot without mak’ ing sure the house is included. When a cow comes nibbling around the edge of the yard she snaps it and me and Maggie and the house. Then she puts the Polaroid in the back seat of the car, and comes up and kisses me on the forehead.

Meanwhile Asalamalakim is going through motions with Maggie’s hand. Maggie’s hand is as limp as a fish, and probably as cold, despite the sweat, and she keeps trying to pull it back. It looks like Asalamalakim wants to shake hands but wants to do it fancy. Or maybe he don’t know how people shake hands. Anyhow, he soon gives up on Maggie.

“Well,” I say. “Dee.”

“No, Mama,” she says. “Not ‘Dee,’ Wangero Leewanika Kemanjo!”

“What happened to ‘Dee’?” I wanted to know.

“She’s dead,” Wangero said. “I couldn’t bear it any longer, being named after the people who oppress me.”

“You know as well as me you was named after your aunt Dicie,” I said. Dicie is my sister. She named Dee. We called her “Big Dee” after Dee was born.

“But who was she named after?” asked Wangero.

“I guess after Grandma Dee,” I said.

“And who was she named after?” asked Wangero.

“Her mother,” I said, and saw Wangero was getting tired. “That’s about as far back as I can trace it,” I said. Though, in fact, I probably could have carried it back beyond the Civil War through the branches.

“Well,” said Asalamalakim, “there you are.”

“Uhnnnh,” I heard Maggie say.

“There I was not,” I said, “before ‘Dicie’ cropped up in our family, so why should I try to trace it that far back?”

He just stood there grinning, looking down on me like somebody inspecting a Model A car. Every once in a while he and Wangero sent eye signals over my head.

“How do you pronounce this name?” I asked.

“You don’t have to call me by it if you don’t want to,” said Wangero.

“Why shouldn’t 1?” I asked. “If that’s what you want us to call you, we’ll call you.”

.

“I know it might sound awkward at first,” said Wangero.

“I’ll get used to it,” I said. “Ream it out again.”

Well, soon we got the name out of the way. Asalamalakim had a name twice as long and three times as hard. After I tripped over it two or three times he told me to just call him Hakim.a.barber. I wanted to ask him was he a barber, but I didn’t really think he was, so I didn’t ask.

“You must belong to those beef.cattle peoples down the road,” I said. They said “Asalamalakim” when they met you, too, but they didn’t shake hands. Always too busy: feeding the cattle, fixing the fences, putting up salt.lick shelters, throwing down hay. When the white folks poisoned some of the herd the men stayed up all night with rifles in their hands. I walked a mile and a half just to see the sight.

Hakim.a.barber said, “I accept some of their doctrines, but farming and raising cattle is not my style.” (They didn’t tell me, and I didn’t ask, whether Wangero (Dee) had really gone and married him.)

We sat down to eat and right away he said he didn’t eat collards and pork was unclean. Wangero, though, went on through the chitlins and com bread, the greens and everything else. She talked a blue streak over the sweet potatoes. Everything delighted her. Even the fact that we still used the benches her daddy made for the table when we couldn’t effort to buy chairs.

“Oh, Mama!” she cried. Then turned to Hakim.a.barber. “I never knew how lovely these benches are. You can feel the rump prints,” she said, running her hands underneath her and along the bench. Then she gave a sigh and her hand closed over Grandma Dee’s butter dish. “That’s it!” she said. “I knew there was something I wanted to ask you if I could have.” She jumped up from the table and went over in the corner where the churn stood, the milk in it crabber by now. She looked at the churn and looked at it.

“This churn top is what I need,” she said. “Didn’t Uncle Buddy whittle it out of a tree you all used to have?”

“Yes,” I said.

“Un huh,” she said happily. “And I want the dasher, too.”

“Uncle Buddy whittle that, too?” asked the barber.

Dee (Wangero) looked up at me.

“Aunt Dee’s first husband whittled the dash,” said Maggie so low you almost couldn’t hear her. “His name was Henry, but they called him Stash.”

 

“Maggie’s brain is like an elephant’s,” Wangero said, laughing. “I can use the chute top as a centerpiece for the alcove table,” she said, sliding a plate over the chute, “and I’ll think of something artistic to do with the dasher.”

When she finished wrapping the dasher the handle stuck out. I took it for a moment in my hands. You didn’t even have to look close to see where hands pushing the dasher up and down to make butter had left a kind of sink in the wood. In fact, there were a lot of small sinks; you could see where thumbs and fingers had sunk into the wood. It was beautiful light yellow wood, from a tree that grew in the yard where Big Dee and Stash had lived.

After dinner Dee (Wangero) went to the trunk at the foot of my bed and started rifling through it. Maggie hung back in the kitchen over the dishpan. Out came Wangero with two quilts. They had been pieced by Grandma Dee and then Big Dee and me had hung them on the quilt ftames on the ftont porch and quilted them. One was in the Lone Stat pattetn. The other was Walk Around the Mountain. In both of them were scraps of dresses Grandma Dee had wotn fifty and more years ago. Bits and pieces of Grandpa Jattell’s Paisley shirts. And one teeny faded blue piece, about the size of a penny matchbox, that was from Great Grandpa Ezra’s unifotm that he wore in the Civil War.

“Mama,” Wangro said sweet as a bird. “Can I have these old quilts?”

I heard something fall in the kitchen, and a minute later the kitchen door slammed.

“Why don’t you take one or two of the others?” I asked. “These old things was just done by me and Big Dee from some tops your grandma pieced before she died.”

“No,” said Wangero. “I don’t want those. They are stitched around the borders by machine.”

“That’ll make them last better,” I said.

“That’s not the point,” said Wangero. “These are all pieces of dresses Grandma used to wear. She did all this stitching by hand. Imag’ ine!” She held the quilts securely in her atms, stroking them.

“Some of the pieces, like those lavender ones, come ftom old clothes her mother handed down to her,” I said, moving up to touch the quilts. Dee (Wangero) moved back just enough so that I couldn’t reach the quilts. They already belonged to her.

“Imagine!” she breathed again, clutching them closely to her bosom.

“The ttuth is,” I said, “I promised to give them quilts to Maggie, for when she matties John Thomas.”

She gasped like a bee had stung her.

“Maggie can’t appreciate these quilts!” she said. “She’d probably be backward enough to put them to everyday use.”

 

“I reckon she would,” I said. “God knows I been saving ’em for long enough with nobody using ’em. I hope she will!” I didn’t want to bring up how I had offered Dee (Wangero) a quilt when she went away to college. Then she had told they were old~fashioned, out of style.

“But they’re priceless!” she was saying now, furiously; for she has a temper. “Maggie would put them on the bed and in five years they’d be in rags. Less than that!”

“She can always make some more,” I said. “Maggie knows how to quilt.”

Dee (Wangero) looked at me with hatred. “You just will not under.stand. The point is these quilts, these quilts!”

“Well,” I said, stumped. “What would you do with them7”

“Hang them,” she said. As if that was the only thing you could do with quilts.

Maggie by now was standing in the door. I could almost hear the sound her feet made as they scraped over each other.

“She can have them, Mama,” she said, like somebody used to never winning anything, or having anything reserved for her. “I can ‘member Grandma Dee without the quilts.”

I looked at her hard. She had filled her bottom lip with checkerberry snuff and gave her face a kind of dopey, hangdog look. It was Grandma Dee and Big Dee who taught her how to quilt herself. She stood there with her scarred hands hidden in the folds of her skirt. She looked at her sister with something like fear but she wasn’t mad at her. This was Maggie’s portion. This was the way she knew God to work.

When I looked at her like that something hit me in the top of my head and ran down to the soles of my feet. Just like when I’m in church and the spirit of God touches me and I get happy and shout. I did some.thing I never done before: hugged Maggie to me, then dragged her on into the room, snatched the quilts out of Miss Wangero’s hands and dumped them into Maggie’s lap. Maggie just sat there on my bed with her mouth open.

“Take one or two of the others,” I said to Dee.

But she turned without a word and went out to Hakim~a~barber.

“You just don’t understand,” she said, as Maggie and I came out to the car.

“What don’t I understand?” I wanted to know.

“Your heritage,” she said, And then she turned to Maggie, kissed her, and said, “You ought to try to make something of yourself, too, Maggie. It’s really a new day for us. But from the way you and Mama still live you’d never know it.”

She put on some sunglasses that hid everything above the tip of her nose and chin.

Maggie smiled; maybe at the sunglasses. But a real smile, not scared. After we watched the car dust settle I asked Maggie to bring me a dip of snuff. And then the two of us sat there just enjoying, until it was time to go in the house and go to bed.