When assessing a patient with suspected appendicitis, the nurse would expect the patient to demonstrate rebound tenderness in which area of the abdomen?
Right upper quadrant
Left lower quadrant
Right lower quadrant
✓
Periumbilical area
Correct Answer
Right lower quadrant
A. Rebound tenderness in the right lower quadrant is most associated with appendicitis.
B. Pain in the left lower quadrant is suggestive of an ovarian cyst or diverticular disease. The appendix is in the right lower quadrant.
C. Right upper quadrant pain is most associated with inflammation or obstruction of the gallbladder.
D. An early sign of appendicitis is periumbilical pain; however, it is vague in nature, and the pain is not usually elicited with palpation over the area.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 2
When assessing a patient who presents with hematochezia, what question regarding the patient’s past medical history is important for the nurse to ask?
“Do you take iron supplements?”
“Do you have a peptic ulcer?”
“Do you have hemorrhoids?”
✓
“Do you have atrial fibrillation?”
Correct Answer
“Do you have hemorrhoids?”
A. Hematochezia (bright red stools) is associated with lower gastrointestinal bleeding. Peptic ulcer disease is usually associated with painful upper gastrointestinal bleeding. The stool would not be bright red.
B. Hematochezia (bright red stools) is associated with lower gastrointestinal bleeding. It would be important to determine if a patient with atrial fibrillation is also taking anticoagulant medications, but atrial fibrillation itself does not contribute to the patient’s risk for gastrointestinal bleeding.
C. Hematochezia (bright red stools) is associated with lower gastrointestinal bleeding. Irritation of hemorrhoids can cause bleeding, which would be bright red and often coat the stool.
D. Hematochezia (bright red stools) is associated with lower gastrointestinal bleeding. Iron supplements will cause the patient’s stool to be black and tarry, and stools associated with upper gastrointestinal bleeding also appear black and tarry.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 3
A patient presents with abdominal pain for the past 3 days. Pain is localized to the epigastric area, with radiation to the right upper quadrant, and became markedly worse after eating dinner last night. Today, the patient complains of nausea and vomiting. The exam reveals tenderness to palpation of the epigastric and right upper quadrants without rebound tenderness. Bowel sounds are normal. The nurse would suspect which of the following?
Cholecystitis
✓
Pancreatitis
Acute gastroenteritis
Esophagitis
Correct Answer
Cholecystitis
A. Pancreatitis usually presents as severe upper abdominal pain that radiates through to the back. The patient may also have nausea and vomiting, along with a low-grade fever.
B. Esophagitis may also present as epigastric pain with occasional vomiting. This is usually caused by the backflow of stomach acid into the esophagus. The discomfort is typically substernal and does not radiate to the abdomen.
C. Acute gastroenteritis can be bacterial or viral in origin and usually presents with nausea, vomiting, and diarrhea, occasionally to the extent of dehydration. The pain is typically described as crampy across the lower abdomen.
D. The most common presentation of acute cholecystitis is that of abdominal pain, typically localized to the right upper quadrant or epigastric area. Radiation to the right shoulder or back may also occur. Acute cholecystitis is characterized by steady and severe pain that is prolonged without improvement. It is associated with the presence of nausea and vomiting.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 4
A patient presents with colicky right flank pain radiating to their groin. The patient is writhing in pain trying to find a comfortable position. The nurse would anticipate preparing the patient for which diagnostic test?
Kidneys, ureters, and bladder radiograph or plain film
Intravenous pyelogram
Correct Answer
Noncontrast helical computed tomography (CT) scan
A. A kidneys, ureters, and bladder radiograph may visualize renal calculi, but it is not considered as sensitive an indicator as the helical CT scan to make the diagnosis of renal calculi. It can be used if the CT scan is not available.
B. The helical CT scan has taken the place of the intravenous pyelogram as the diagnostic test of choice for renal calculi.
C. Although renal calculi may be visualized in an ultrasound, this diagnostic procedure is not considered a sensitive indicator to diagnose the presence of renal calculi due to poor visualization of nondilated ureters.
D. This patient most likely has a renal calculus (kidney stone). The gold standard for confirming a renal stone (calculi) is a noncontrast helical CT scan.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 5
A patient presents for abdominal pain. They report having felt fatigued, itchy, and “out of it” for the past several weeks. Upon exam, the abdomen is distended, and the skin is orange. The nurse recognizes that this is probably cirrhosis, and the most common cause is:
chronic hepatitis B.
end-stage cardiac disease.
nonalcoholic or fatty liver disease.
excessive alcohol consumption.
✓
Correct Answer
excessive alcohol consumption.
A. This form of cirrhosis is caused by fat deposits in an already inflamed liver. Risk factors include severe obesity, diabetes, and severe weight loss. As obesity rates rise, so will the incidence of fatty liver disease.
B. Hepatitis B, like hepatitis C, is due to a viral infection that causes inflammation and damage to the liver. Excessive alcohol consumption and chronic hepatitis C are common causes of cirrhosis.
C. Alcohol consumption is a common cause of cirrhosis. Alcohol is absorbed in the small intestine, and blood transports it directly to the liver, where it is then converted into a toxic chemical.
D. Patients with end-stage cardiac disease may have symptoms of chronic liver disease, but it is not a common cause of cirrhosis.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 6
A patient presents with ascites and jaundice. Which elevated laboratory test is most indicative of cirrhosis?
Serum aminotransferases
✓
White blood cell (WBC) count
Serum acid phosphate level
Red blood cell count
Correct Answer
Serum aminotransferases
A. Increased red blood cell counts can be seen in dehydration, renal cell carcinoma, and cigarette smoking, but not cirrhosis.
B. A change in acid phosphatase is seen with prostate cancer, benign prostatic hypertrophy, and multiple myeloma.
C. An elevated WBC count is usually seen with infections. Cirrhosis is not due to an infection, but there can be an elevated WBC count; however, it is not the determining lab value.
D. Elevated aminotransferases, including alanine transaminase (ALT), aspartate transaminase (AST), and alkaline phosphatase (ALP), correlate with liver damage and cirrhosis. Common causes are nonalcoholic fatty liver disease and alcoholic liver disease.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 7
A patient arrives with a complaint of left lower quadrant abdominal pain, loose stools, and fever. They have no significant history. On exam, you find that the patient has tenderness and guarding of the left lower quadrant and a white blood cell count of 15,000. The diagnosis is diverticulitis, and the patient will be admitted. What intervention might the nurse prepare the patient to expect?
Ultrasound of the abdomen and an anticholinergic
Administration of an antibiotic and an anticholinergic
✓
Endoscopy in the next 24 hours and a proton pump inhibitor
Administration of a proton pump inhibitor and an antibiotic
Correct Answer
Administration of an antibiotic and an anticholinergic
A. Endoscopy is contraindicated in the presence of diverticulitis because of the possibility of perforation. Endoscopy may be appropriate later once the inflammation process has subsided. Proton pump inhibitors reduce the secretion of gastric acid and are the treatment of choice for peptic ulcer disease.
B. Antibiotic (IV or PO) therapy is appropriate for moderate to severe disease, with PO used in mild disease, along with an anticholinergic to reduce colonic spasms.
C. An abdominal computed tomography scan, possibly with barium swallow, is the diagnostic test of choice, not an ultrasound; the anticholinergic is used to reduce colonic spasms.
D. Proton pump inhibitors reduce the secretion of gastric acid and are the treatment of choice for peptic ulcer disease.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 8
Which of the following is a priority intervention for a patient with bleeding esophageal varices?
Initiate high-flow oxygen
Establish intravenous (IV) access
Infuse two units of whole blood
Secure the patient’s airway
✓
Correct Answer
Secure the patient’s airway
A. IV fluid replacement and blood administration are indicated only after the patient’s airway is determined to be open and secured.
B. The patient will likely need fluid replacement, and IV access with two large-caliber catheters may be indicated. However, this can be established once the patient’s airway is patent and secured.
C. Bleeding esophageal varices present an immediate threat to the patient’s airway patency. The priority intervention is to determine that the airway is open, patent, and secured.
D. Oxygen administration is an important intervention, especially if the patient is showing signs of hemodynamic compromise or hypovolemic shock; however, securing the airway is the priority.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 9
A patient presents via emergency medical services with a 72-hour history of vomiting and diarrhea. The patient’s heart rate is elevated, skin is pale, and they are hard to arouse. The nurse is aware that the priority management for this patient is to perform which of the following?
Secure the airway and maintain breathing
✓
Establish intravenous access (IV) for administration of fluids
Administer antiemetics
Obtain a stool sample
Correct Answer
Secure the airway and maintain breathing
A. Obtaining a stool sample to determine the cause of the gastroenteritis is important for treatment and recovery of the patient, but emergency management of the airway and breathing, and circulation, should be the priority.
B. IV access and administration of fluids is an important treatment because the patient is exhibiting signs of dehydration. However, priority treatment would be airway management, followed by obtaining IV access.
C. Pharmacologic management of vomiting and diarrhea will be included in the treatment, but emergency management of the airway must be considered first.
D. Because of the continued vomiting and difficulty arousing the patient, the patient’s airway may become compromised. The priority would be to manage the patient’s airway and breathing while establishing IV access and continuing other treatments.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 10
A patient has been diagnosed with hepatitis C. Which of the following statements from the patient after they received patient education regarding the diagnosis indicates their correct understanding of the disease?
“I know I can be infected even though I don’t have any symptoms.”
✓
“I never used intravenous drugs or had unprotected sex with multiple partners, even when I was much younger.”
“My partner will need to be vaccinated so they won’t become infected too.”
“I’ll separate my eating and drinking utensils from those used by other family members.”
Correct Answer
“I know I can be infected even though I don’t have any symptoms.”
A. Hepatitis C is transmitted by contact with blood infected with the hepatitis C virus. It is not spread by sharing eating utensils or through casual contact with an infected individual.
B. Intravenous drug use and unprotected sexual contact with persons infected with the hepatitis C virus are risk factors associated with the transmission of the virus; however, persons born between 1945 and 1965 are at an additional risk to have contracted hepatitis C from medical equipment or procedures performed before the adoption of universal precautions. Blood transfusions were not screened for the hepatitis virus until 1992.
C. There is no vaccine to prevent the transmission of hepatitis C.
D. Individuals who are infected with hepatitis C may be asymptomatic for a long time before they develop symptoms that would lead them to seek medical care.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 11
A patient presents with a complaint of poorly localized abdominal pain, nausea, and bilious vomitus for the past day. They also state no stools or passing of any flatus during this time. On physical exam, there is diffuse tenderness to palpation of the abdomen but no rebound tenderness or guarding. The plan is to admit the patient to the medical floor. The nurse can anticipate discussing which elements of care with the patient?
Insertion of a urinary catheter and administering antibiotics
Insertion of a duodenal tube and kept NPO
Insertion of gastric tube and kept NPO
✓
Insertion of a duodenal tube and administering antiemetics
Correct Answer
Insertion of gastric tube and kept NPO
A. A duodenal tube is used for feedings, not for decompression. The patient is kept NPO for the bowel to rest.
B. A duodenal tube is used for feedings, not for decompression. Antiemetics may be used for the nausea and vomiting that this patient is experiencing.
C. A gastric tube is inserted for decompression, and NPO is to provide bowel rest for the patient.
D. A urinary catheter may be inserted for a patient who is hemodynamically unstable, and antibiotics may be indicated if there is a perforation or elevated white blood cell count.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 12
What type of electrolyte imbalance would the nurse expect to see with an attack of acute pancreatitis?
Hypophosphatemia
Hyperglycemia
✓
Hypercalcemia
Hypoglycemia
Correct Answer
Hyperglycemia
A. Elevated calcium levels are uncommon in acute pancreatitis. Hypocalcemia is seen frequently.
B. Glucose is elevated, not decreased, in a patient with acute pancreatitis.
C. Phosphate is elevated along with liver enzymes in a patient with acute pancreatitis.
D. Serum chemistries, including BUN, creatinine, and glucose, are all elevated in a patient with acute pancreatitis.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 13
The nurse would anticipate hospital admission for a patient diagnosed with renal calculi (renal stones) if the patient demonstrated which of the following?
Inability to tolerate oral fluids
✓
Continued mild pain
Renal calculi size of 4 mm
Hematuria
Correct Answer
Inability to tolerate oral fluids
A. Renal calculi greater than 5 mm will be difficult to pass through the genitourinary system and may require hospitalization for stone dissolution, lithotripsy, or surgical intervention. Renal calculi smaller than 6 mm can pass through the renal system and be eliminated by the body.
B. An increased intake of oral fluids is necessary to facilitate the passage of renal calculi through the genitourinary system. Patients who are unable to tolerate oral intake will require hospital admission for intravenous fluid administration to facilitate the passage of the renal calculi.
C. Pain may persist but can be treated with nonsteroidal anti-inflammatory medications and narcotic analgesics. If these analgesics are not effective for pain relief, the patient should be advised to return to the emergency department, at which time hospital admission may be considered.
D. Microscopic or gross hematuria is an expected finding for a patient with renal calculi and should not necessitate hospital admission.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 14
A bicyclist presents after crashing into a wall and flying over the handlebars. They are awake and alert, with a complaint of left-sided abdominal pain with nausea. Vital signs are BP 124/60 mm Hg, HR 80 beats/minute, RR 16 breaths/minute, SpO 98%. The nurse would anticipate which diagnostic test to assess for possible 2 intra-abdominal injury?
Computed tomography (CT) scan of the abdomen and pelvis with contrast
Focused assessment with sonography for trauma (FAST)
✓
Exploratory laparotomy
Diagnostic peritoneal lavage
Correct Answer
Focused assessment with sonography for trauma (FAST)
A. A peritoneal lavage is an invasive procedure that is indicated if the patient is hemodynamically unstable and transport to a CT scanner would place the patient at risk for complications.
B. Indications for exploratory laparotomy include evidence of shock without obvious blood loss, determination of free air in the abdomen, or an alteration in level of consciousness. Vital signs are stable, and the patient does not show evidence of obvious blood loss or shock.
C. In a stable patient presenting with a potential abdominal injury, a CT scan of the abdomen and pelvis would be indicated if a FAST was positive for intraperitoneal fluid.
D. This patient’s mechanism of injury and complaints of abdominal pain are highly suspicious for intra-abdominal injury due to blunt abdominal trauma. Because this patient is hemodynamically stable, a bedside FAST is indicated prior to a CT scan.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 15
Following the incision and drainage of a Bartholin’s gland abscess, the patient’s discharge teaching instructions should include which of the following?
Your sexual partners will not need to be treated for this infection.
Having an intrauterine device (IUD) puts you at greater risk for developing a Bartholin’s gland abscess.
Follow up with your healthcare provider to have the drainage (Word) catheter removed in 24 hours.
Take a sitz bath or soak in a bathtub with warm water several times a day.
✓
Correct Answer
Take a sitz bath or soak in a bathtub with warm water several times a day.
A. The most common causative organisms of the Bartholin’s gland abscess are E. coli and G. vaginalis. If these organisms are the cause of the abscess, sexual partners do not require antibiotic treatment. Less commonly, N. gonorrhea and C. trachomatis have been identified by culture; in these cases, sexual partners will require antibiotic treatment.
B. The patient should be instructed to use a sitz bath or soak in a warm tub for 10–15 minutes 3–4 times per day.
C. A drainage (Word) catheter is placed in the Bartholin’s gland abscess to facilitate drainage. The catheter should stay in place for several weeks to prevent abscess recurrence.
D. The presence of an IUD places the patient at greater risk for developing pelvic inflammatory disease because of the upward migration of infectious organisms. IUDs do not increase the patient’s risk for developing a Bartholin’s gland abscess.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 16
A female presents with complaints of right lower abdominal pain and nausea. Vital signs are stable. Ultrasound indicates an ectopic pregnancy that is 2.8 cm in size. Which of the following medications would be the priority intervention for this patient?
Medroxyprogesterone
Methotrexate
✓
Oxytocin
Rh D immune globulin o
Correct Answer
Methotrexate
A. If the mother is RH negative, immunization with RhoD immune globulin may be indicated to prevent Rh incompatibility in future pregnancies, but it will not terminate the existing ectopic pregnancy.
B. Oxytocin is a uterine stimulant that is used to induce labor. Oxytocin is an effective treatment for the delivery of an intrauterine pregnancy, but not an ectopic pregnancy.
C. Methotrexate is an antimetabolite that prevents further duplication of the fetal cells. It is administered intramuscularly, and the patient is then followed with quantitative serum beta human gonadotropin (β-hCG) levels.
D. Medroxyprogesterone is a form of progesterone that helps regulate ovulation and menstrual periods. It is used to treat conditions such as absent or irregular menstrual periods; it is not indicated as a treatment for ectopic pregnancy.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 17
A patient with postpartum hemorrhage is receiving an infusion of 20 units of oxytocin in 1000 mL of Ringer’s lactate solution. Which of the following outcomes would indicate the desired effect of this medication?
Decreased abdominal discomfort
Decreased vaginal bleeding
✓
Decreased blood pressure
Decreased firming of the uterus
Correct Answer
Decreased vaginal bleeding
A. Decreased blood pressure is not the desired effect of oxytocin; rather, a decrease in blood pressure may be a sign of hypovolemic shock in a postpartum patient.
B. Postpartum hemorrhage most commonly occurs because of uterine atony. Oxytocin is a vasoconstrictor that stimulates uterine contractions, improves uterine tone, and reduces postpartum bleeding.
C. Oxytocin will stimulate painful uterine contractions as it restores uterine tone, so abdominal discomfort is an expected effect of oxytocin administration.
D. The cause of the bleeding may likely be from uterine atony, and a soft and boggy uterus is a sign of atony. A firmer uterus is the desired effect of oxytocin administration.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 18
Which of the following is the priority intervention for a prolapsed cord during an emergency delivery?
The mother should be placed in semi-Fowler’s position.
The cord should be pushed back into position under the fetal head.
Reverse Trendelenburg position should be employed.
A hand should be placed under the head of the fetus, with a gentle lift.
✓
Correct Answer
A hand should be placed under the head of the fetus, with a gentle lift.
A. Semi-Fowler’s position would be contraindicated because it would cause more cord compression and subsequent hypoxia for the fetus. Excessive Trendelenburg or knee–chest positions would better encourage blood flow to the fetus.
B. Until an emergency cesarean section can be accomplished, the cord must be decompressed by placing a hand under the fetal head while lifting the head enough to allow blood flow. The feel of pulsations against the hand would be a positive indicator that flow is occurring. It is important to not place undue stress on the cord because it can cause vasospasm, leading to hypoxia for the infant.
C. Reverse Trendelenburg would be contraindicated in this situation. It would create more compression on the cord and cause fetal death. A sharp Trendelenburg or knee–chest position would be the more acceptable positions to encourage blood flow to the fetus.
D. No attempt should be made to push or reposition the cord back into the vaginal vault under the presenting part. It has been proved to be deleterious to the fetus.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 19
Which of the following is the characteristic finding with placenta previa?
Painless bright red vaginal bleeding
✓
Painful dark red vaginal bleeding
Vaginal discharge of blood-tinged mucus
Vaginal passing of fetal tissue
Correct Answer
Painless bright red vaginal bleeding
A. A third-trimester emergency associated with painful vaginal bleeding is abruptio placentae. This can also occur with very little or no vaginal bleeding, depending on the degree of the placental abruption. The bleeding with this disorder is bright red.
B. Painless bright red vaginal bleeding is the most characteristic clinical finding of placenta previa, which occurs when the placenta has implanted, either totally or partially, over the cervical os. As the uterus expands because of fetal growth, the implantation of the placenta is disturbed, and bleeding can occur through the cervix. The uterus is not contracting, so the bleeding is painless.
C. Blood-tinged mucus discharge, also known as a “bloody show,” is a normal sign associated with impending delivery.
D. The passing of tissue, also known as the products of conception, is suggestive of a spontaneous abortion.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 20
Chest compressions should be started on a neonate with adequate ventilations if the heart rate falls below which of the following beats per minute?
60
✓
120
100
80
Correct Answer
60
A. The normal heart rate for a full-term newborn is 90–170 beats/minute. It is recommended that chest compression be initiated if the infant’s heart rate is below 60 beats/minute despite adequate ventilations.
B. The normal heart rate for a full-term newborn is 90–170 beats/minute. The recommendation for initiation of chest compressions is for heart rates of 60 beats/minute or less despite adequate ventilations.
C. The normal heart rate for a full-term newborn is 90–170 beats/minute. Chest compressions would not be indicated for a newborn with a heart rate of 110 beats/minute.
D. This heart rate is well within the normal range for a full-term infant. Chest compressions would not be indicated.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 21
A patient presents 4 days postpartum from a vaginal delivery with high fever and rigors. The vulva is edematous and tender to touch, with ecchymosis of the left labia extending to the buttocks unilaterally and the presence of a “foul-smelling” discharge from the episiotomy site. Subcutaneous emphysema is noted with crepitus. The patient is tachycardic, hypotensive, and tachypneic. Which of the following is the priority intervention for this patient?
Emergent surgery
✓
Hyperbaric chamber
Antipyretics
Incision and drainage
Correct Answer
Emergent surgery
A. Necrotizing fasciitis is a severe wound infection involving superficial and deep fascia. It is frequently associated with episiotomy or other perineal trauma during delivery and has a high mortality rate. Hyperbaric chamber treatment for necrotizing fasciitis is available, but it does not take the place of surgical intervention.
B. Necrotizing fasciitis is a severe wound infection involving superficial and deep fascia. It is frequently associated with episiotomy or other perineal trauma during delivery and has a high mortality rate. Antipyretics can help with symptoms but do not treat the problem.
C. Necrotizing fasciitis is a severe wound infection involving superficial and deep fascia. It is frequently associated with episiotomy or other perineal trauma during delivery and has a high mortality rate. Incision and drainage of the site is not adequate for treatment of necrotizing fasciitis.
D. Necrotizing fasciitis is a severe wound infection involving superficial and deep fascia. It is frequently associated with episiotomy or other perineal trauma and has a high mortality rate. The patient can present with ecchymosis and swelling of the vulva, high fever, subcutaneous emphysema, and shock, and requires aggressive management. Emergent surgery to debride the area is crucial to survival.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 22
An adult patient presents with partial-thickness burns to their anterior trunk and both arms circumferentially from a campfire. Based on the “rule of nines,” what is this patient’s estimated burned total body surface area (TBSA)?
36%
✓
54%
45%
27%
Correct Answer
36%
A. For this patient, each arm is 9% (4.5% anterior and 4.5% posterior), and the anterior trunk is 18%. This is an underestimation of the burn surface area, and the patient would not receive adequate fluid resuscitation for the sustained injuries.
B. The rule of nines is a method that divides areas of the body into multiples of 9. For this patient, each arm is 9% (4.5% anterior and 4.5% posterior), and the anterior trunk is 18%, for a TBSA of 36%.
C. For this patient, each arm is 9% (4.5% anterior and 4.5% posterior), and the anterior trunk is 18%. This is an overestimation of the total burn area and may result in excessive fluid resuscitation.
D. For this patient, each arm is 9% (4.5% anterior and 4.5% posterior), and the anterior trunk is 18% This is an overestimation of the total burn area and could result in excessive fluid resuscitation.
Category: Environment and Toxicology Emergencies, and Communicable
Question 23
A patient arrives following a house fire. The patient is flushed, disoriented to time, place, and person, and nauseated, and complains of a severe headache. Which of the following testing modalities would provide the best information in the diagnosis of this patient?
Arterial blood gas
Capnography
Pulse oximetry
Carboxyhemoglobin level
✓
Correct Answer
Carboxyhemoglobin level
A. The patient is exhibiting signs of carbon monoxide poisoning, which includes flushing, headache, disorientation, and nausea. To adequately determine the patient’s level of carbon monoxide, a carboxyhemoglobin level must be obtained.
B. This patient is at high risk for carbon monoxide (CO) poisoning. Pulse oximetry measures saturation of oxygen but cannot differentiate between hemoglobin saturated with carbon monoxide or saturated with oxygen; therefore, it can provide a false reading of oxygen saturation.
C. This patient is at high risk for carbon monoxide (CO) poisoning. Oxygen dissolved in blood plasma (PaO ) is usually unaffected by CO poisoning. An arterial 2 blood gas test will not provide the information required to evaluate the patient’s level of carbon monoxide poisoning.
D. This patient is at high risk for carbon monoxide (CO) poisoning. Capnography is the measurement of expired carbon dioxide levels in the airway and is not a measurement of carboxyhemoglobin.
Category: Environment and Toxicology Emergencies, and Communicable
Question 24
After being sprayed by a crop duster, a patient presents with excessive tearing, salivation, nausea, vomiting, and confusion. Which of the following intravenous medications should be anticipated for this patient?
Sodium nitrite
Atropine
✓
Naloxone
Flumazenil
Correct Answer
Atropine
A. Naloxone is used to treat opiate ingestion or an opiate intravenous overdose; it is not indicated in the treatment of organophosphate poisoning, which is indicated by the risk factors and manifestations in the question stem.
B. This patient is exhibiting symptoms of organophosphate poisoning. Immediate treatment for this is the administration of intravenous atropine, followed by pralidoxime (2-PAM).
C. Sodium nitrite is the antidote for cyanide poisoning; it is not used in the treatment of organophosphate poisoning, which is indicated through the mechanism of injury and manifestations in the question stem.
D. Flumazenil is used in the treatment of benzodiazepine overdoses; it is not indicated in the treatment of organophosphate poisoning, which is demonstrated by the potential mechanism of injury and manifestations of the patient in the question stem.
Category: Environment and Toxicology Emergencies, and Communicable
Question 25
Which of the following factors is considered to be most important in survival rates of drowning victims?
Type of water (saltwater or freshwater)
Speed of rewarming the victim
Initial Glasgow Coma Scale score of 3 or greater
Immediate cardiopulmonary resuscitation (CPR)
✓
Correct Answer
Immediate cardiopulmonary resuscitation (CPR)
A. Field resuscitation of the near-drowning victim is crucial for survival. Performing immediate basic life support procedures (CPR) on the victim immediately after removal from the water has been cited as a significant factor in the victim’s survival. Rescue breathing should be started as soon as possible, including in the water if it is feasible.
B. Rewarming efforts should be aggressive if the victim’s core temperature is below 30°C (86°F) but do not outweigh early CPR in survivability.
C. Although saltwater and freshwater differ significantly in composition, these differences do not affect survival in near-drowning incidents. Immediate basic life support for the drowning victim is a significant factor in survival.
D. A patient’s initial Glasgow Coma Scale score has not been shown to increase survival in drowning incidents.
Category: Environment and Toxicology Emergencies, and Communicable
Question 26
Which of the following medications would most likely need to be administered to a patient with a dermal burn from hydrofluoric acid?
Potassium chloride
Calcium gluconate
✓
Hydroxocobalamin
Atropine
Correct Answer
Calcium gluconate
A. Hydrofluoric acid dermal burns can cause systemic hypocalcemia, requiring the administration of calcium gluconate for correction. Calcium gluconate gel is used at the site of the burn to neutralize the acid. Intravenous calcium gluconate is used for the systemic reaction as the fluoride ions bind with the available calcium.
B. Hydrofluoric acid can alter the sodium–potassium pump site on cells, allowing for potassium to leak into the serum, causing hyperkalemia. The use of potassium chloride with hydrofluoric acid burns would not be correct.
C. Hydroxocobalamin (vitamin B ) is used to treat cyanide poisoning, not 12 hydrofluoric acid burns.
D. Atropine would be used to treat an organophosphate poisoning. Hydrofluoric acid burns can cause a systemic hypocalcemia and would need infusion of calcium gluconate to treat this.
Category: Environment and Toxicology Emergencies, and Communicable
Question 27
A patient caring for a child with measles (rubeola) is 11 weeks pregnant. She is unsure of her vaccination status. Which of the following would be the expected intervention for this patient post exposure?
Course of oral antibiotics
Administration of immune globulin
✓
MMR (measles, mumps, rubella) vaccination
Vitamin A injection
Correct Answer
Administration of immune globulin
A. Pregnant patients who are exposed to rubeola should receive intravenous immune globulin to help protect them from miscarriage, stillbirths, preterm delivery, and low-birth-weight babies. The MMR vaccine should not be used during pregnancy.
B. Pregnant patients exposed to rubeola should not receive the MMR vaccination. Before pregnancy and after delivery would be safe times to obtain this vaccination.
C. Rubeola is a viral illness. Antibiotics will not help with prevention or treatment of this vaccine-preventable disease.
D. Vitamin A injection will not help with postexposure prophylaxis for rubeola. For some patients with rubeola, vitamin A can be considered a form of therapy to help with the issue of vitamin A depletion during the disease.
Category: Environment and Toxicology Emergencies, and Communicable
Question 28
Which of the following is a used in the treatment of cyanide poisoning?
Hydroxocobalamin
✓
Sodium polystyrene sulfonate
Dimercaprol
N-acetylcysteine
Correct Answer
Hydroxocobalamin
A. N-acetylcysteine increases liver stores of glutathione for acetaminophen toxicity.
B. Dimercaprol is used for chelation therapy in acute lead encephalopathy.
C. Hydroxocobalamin, along with sodium nitrite and sodium thiosulfate, are the currently available antidotes for cyanide poisoning. Amyl nitrite is no longer considered an acceptable intervention.
D. Sodium polystyrene sulfonate or kayexalate is indicated for hyperkalemia.
Category: Environment and Toxicology Emergencies, and Communicable
Question 29
The nurse is caring for a patient who has presented directly from their primary care provider for hydration therapy, secondary to 2 days of watery diarrhea and the presence of blood in their stool. Which of the following puts the patient at greatest risk for contracting a Clostridium difficile (C. difficile) infection?
“I’ve been taking penicillin for an infection for several weeks.”
✓
“I work on a farm around cattle and livestock every day.”
“I just returned from traveling in Africa for 2 weeks.”
“I work at a daycare with toddlers all day.”
Correct Answer
“I’ve been taking penicillin for an infection for several weeks.”
A. Working in and around young children would not be a risk factor for contracting a
C. difficile infection.
B. Risk factors for contracting C. difficile include antibiotic exposure, proton pump inhibitor use, gastrointestinal surgery/manipulation, long length of stay in a healthcare setting, serious underlying illness, immunocompromising conditions, and advanced age.
C. Working around livestock is not a risk factor for a contracting a C. difficile infection.
D. International travel is not a risk factor for contracting a C. difficile infection.
Category: Environment and Toxicology Emergencies, and Communicable
Question 30
Which of the following is a mandatory reportable disease to the Centers for Disease Control and Prevention (CDC)?
Pneumonia
Hand, foot, and mouth disease
Measles (rubeola)
✓
Urinary tract infections (UTIs)
Correct Answer
Measles (rubeola)
A. UTIs are typically bacterial in nature and are not contagious. UTIs do not need to be reported to the CDC.
B. Pneumonia can be either bacterial or viral but does not need to be reported to the CDC. The total number of cases may be reported within a given region, but it is not a mandatory disease to report.
C. Hand, foot, and mouth disease is a highly contagious viral illness that causes sores to the hands, feet, and mouth. It is not a reportable disease to the CDC, but it should be reported to anyone who may have come into contact with the virus.
D. Measles (rubeola) is an acute and highly contagious viral illness caused by the rubeola virus. It must be reported by phone to the CDC by the patient’s provider.
Category: Professional Issues, System, Symptom surveillance (e.g., mandatory
Question 31
An unrestrained driver with no medical history is brought to the emergency department following a motor vehicle collision. The patient reports hitting their chest on the steering wheel and is complaining of chest pain across the front of their chest. Vital signs are within normal limits, and there are no other complaints of pain. On assessment, an additional heart sound is noted. What should the nurse expect as the diagnosis?
Cardiac tamponade
Tension pneumothorax
Blunt cardiac injury
✓
Flail chest
Correct Answer
Blunt cardiac injury
A. Blunt cardiac injuries are usually the result of blunt-force impacts to the chest. The most common mechanism of injury is a direct impact to the chest in a motor vehicle crash. Clinical manifestations associated with blunt cardiac injuries can include localized chest pain, S gallop, diffuse crackles, 3 and electrocardiogram changes.
B. Tension pneumothorax is a life-threatening traumatic injury. It occurs after a rupture of a bleb causes air to leak into the thoracic cavity, causing a mediastinal shift. Clinical manifestations include increased work of breathing, anxiety, hypotension, tachycardia, tracheal deviation, and decreased or absent breath sounds on the affected side.
C. Flail chest occurs when two or more adjacent ribs are fractured in two or more locations or when the sternum is detached. Clinical manifestations are restlessness, hypotension, tachycardia, paradoxical chest movements, shallow breathing, and bony crepitus or deformity.
D. Cardiac tamponade can occur with a traumatic injury that allows blood to accumulate in the pericardial sac, decreasing cardiac output by restricting the heart’s ability to pump. Classic clinical manifestations are known as Beck’s triad: distended neck veins, muffled heart sounds, and hypotension.
Category: Cardiovascular Emergencies, Cardiovascular trauma
Question 32
A patient presents with a complaint of chest pain that radiates to the jaw. The 12-lead electrocardiogram (ECG) shows an inferior wall myocardial injury pattern. What intervention should be performed next?
Chest radiograph
Creatine kinase-MB (CK-MB)
Right-sided ECG
✓
Echocardiogram
Correct Answer
Right-sided ECG
A. All patients with suspected inferior or lateral acute myocardial infarction should be evaluated for right ventricular infarction. It is present in up to 40% of patients with inferior myocardial infarctions. The more reliable method for evaluating for this type of infarction is the use of a right-sided ECG.
B. Chest radiograph may diagnose pulmonary etiology that can be associated with acute myocardial infarction, but it is not a priority.
C. An echocardiogram may show the extent of damage to the cardiac muscle, but it is not a priority at this time.
D. CK-MB was once the gold standard for acute myocardial infarction; however, it has been replaced with a more specific cardiac biomarker: troponin. Also, it is important to assess for the presence of a right ventricular infarction since the initial ECG suggested an infarction.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 33
During transcutaneous pacing for a patient with third-degree heart block, there is a loss of ventricular capture. Which is a significant physiological reason for loss of pacemaker capture?
Hypomagnesemia
Hypokalemia
Metabolic acidosis
✓
Metabolic alkalosis
Correct Answer
Metabolic acidosis
A. Metabolic alkalosis may present with atrial tachycardia and can be related to hypotension because of excessive fluid loss related to gastrointestinal losses or diuretic abuse.
B. Hypomagnesemia may present with torsades de pointes, ventricular tachycardia, and/or ventricular fibrillation, but it is not associated with loss of pacemaker capture.
C. Metabolic acidosis and hypoxemia are two possible reasons for ineffective capture while externally pacing a patient.
D. Hypokalemia presents with the presence of U-waves on the electrocardiogram, ventricular dysrhythmias, or pulseless electrical activity, but it is not associated with loss of pacemaker capture.
Category: Cardiovascular Emergencies, Dysrhythmias
Question 34
A patient is being discharged with a prescription for nitroglycerin (NTG) tablets. Which statement by the patient acknowledges that discharge teaching has been effective?
“If my chest pain has not gone away after I have taken 2 tablets, I will come to the hospital.”
✓
“I will call my doctor every time I need to take a tablet for my chest pain.”
“I should keep the tablets on my windowsill in the kitchen so I can find them easily.”
“I am to take the tablets at least every 2–3 minutes when I experience chest pain.”
Correct Answer
“If my chest pain has not gone away after I have taken 2 tablets, I will come to the hospital.”
A. Patients are instructed to take one NTG tablet every 5 minutes. The onset of action of NTG is 1–3 minutes after administration. Taking the medication more frequently can result in excessive vasodilation, which can lead to an altered level of consciousness and hypotension.
B. It is not appropriate to call the physician each time a NTG tablet is taken. Many patients can experience relief of their chest discomfort following only one NTG tablet.
C. NTG should be kept in a small, dark bottle stored in a cool, dark place to enhance the longevity of the medication. Extra or excess tablets can be kept in the refrigerator to increase longevity.
D. NTG should result in vasodilation of the coronary arteries, leading to improved blood flow and a decrease in the patient’s chest discomfort. Patients are instructed to seek further medical care if their chest pain has not subsided after taking 2–3 NTG tablets 5 minutes apart.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 35
To limit the recurrence of chronic obstructive pulmonary disease (COPD) exacerbations, it is important that patients should perform which intervention?
Get a pneumococcal vaccine
Take medications as directed
Stop smoking
✓
Daily exercise
Correct Answer
Stop smoking
A. Smoking irritates lung tissue, causing pulmonary inflammation, and damages the alveoli. Continuous irritation decreases the lungs’ ability to function normally. Not smoking is the most important way to prevent further lung damage and to limit the recurrence of COPD exacerbations.
B. Exercise can help by increasing a patient’s physical stamina and lung capacity. Pulmonary rehabilitation also addresses related issues such as depression and nutrition. However, exercise and pulmonary rehabilitation will not prevent recurrence of COPD exacerbations.
C. Taking prescribed medications such as bronchodilators when symptoms are mild may prevent airway constriction from worsening, but it will not limit the frequency of exacerbations.
D. Patients with COPD are at greater risk of complications from secondary illnesses, such as pneumonia. However, receiving the pneumonia vaccine will not decrease the frequency of exacerbations.
Category: Respiratory Emergencies, Chronic obstructive pulmonary disease
Question 36
The student nurse asks the nurse preceptor why it is important to keep the head of the bed elevated for a patient who is receiving an enteral feeding. What would be the best response by the nurse preceptor?
“Keeping the head of the bed elevated prevents the feeding tube from becoming occluded as the tube feeding flows into the stomach.”
“The head of the bed is elevated to increase patient comfort when sitting up in bed during feeding.”
“The head of the bed is elevated to facilitate the tube feeding formula getting to the patient faster, thereby helping to reduce a negative nitrogen balance from lack of nutrition.”
“Keeping the head of the bed elevated helps to prevent reflux, which can lead to aspiration pneumonia.”
✓
Correct Answer
“Keeping the head of the bed elevated helps to prevent reflux, which can lead to aspiration pneumonia.”
A. If no contraindications exist, the head of the patient’s bed should be elevated to minimize the risk of aspiration. A patient who is immobile should also be turned every 2 hours to prevent the development of pressure ulcers.
B. Lying supine increases the risk of aspiration while receiving enteral formula; having the head of the bed raised will not increase the rate of nutrition absorption.
C. Placing the patient in a supine position during enteral feedings can result in reflux and subsequent aspiration, leading to pneumonia. All patients who are receiving enteral feeding should be in semi-Fowler’s position to minimize the risk of aspiration pneumonia.
D. The head of the bed is elevated to prevent any aspiration of the formula into the lungs, which could result in pneumonia. An enteral feeding should be placed on a pump to prevent the patient from receiving formula too fast.
Category: Respiratory Emergencies, Infections
Question 37
A patient has just been intubated and placed on mechanical ventilation. What measure can the nurse initiate to reduce the risk of ventilator-associated pneumonia (VAP)?
Elevate the head of the bed
✓
Verify that the endotracheal tube cuff is deflated
Keep the patient supine
Only suction the patient once a shift
Correct Answer
Elevate the head of the bed
A. A patient should be suctioned whenever there are oral secretions present to prevent aspiration of the secretions; aspiration allows bacteria to enter the respiratory tract, leading to VAP.
B. Unless contraindicated, an intubated patient should not remain supine. A supine position increases the risk of aspiration and VAP. Keeping the patient in a semi-recumbent position with the head of the bed between 30 and 45 degrees aids in reducing the incidence of gastroesophageal reflux and the potential for aspiration.
C. An intubated patient who requires mechanical ventilation should have the endotracheal (ET) tube cuff inflated to minimize the risk of aspiration. Oral secretions and gastric secretions from reflux can enter the trachea, leading to aspiration pneumonia if the ET tube cuff is not inflated.
D. Elevation of the head of the bed and oral care with chlorhexidine are measures that assist in preventing VAP.
Category: Respiratory Emergencies, Infections
Question 38
A patient arrives via emergency medical services with suspected carbon monoxide poisoning. The patient is alert to painful stimuli and is demonstrating intermittent snoring-type respirations. After opening the airway and administering high-flow supplemental oxygen, what assessment finding would indicate that the patient is receiving adequate oxygenation?
Pulse oximetry reading of 100%
Responds to verbal stimuli
✓
pCO level of 50 mm Hg 2
Responds to painful stimuli
Correct Answer
Responds to verbal stimuli
A. The normal pCO level is 35–45 mm Hg. A pCO of 50 mm Hg is an indication of 2 2 poor ventilation with retention of carbon dioxide.
B. Pulse oximetry only detects saturated hemoglobin and does not differentiate between oxygen and carbon monoxide, so the pulse oximetry reading is not a reliable indicator of oxygen delivery to tissues.
C. If the patient is still responding only to painful stimuli, no improvement has been shown postintervention.
D. The patient responding to verbal stimuli is an improvement in level of consciousness postintervention.
Category: Respiratory Emergencies, Inhalation injuries
Question 39
Following introduction of the participants, which of the following statements would be used at the beginning of a critical incident stress debriefing?
“Can you provide a brief description of what happened during the event from your viewpoint?”
✓
“Can you tell us what you think should have been done differently?”
“Can you tell us what you perceive to be the positive outcomes of this event?”
“Can you describe how you are feeling after going through this event?”
Correct Answer
“Can you provide a brief description of what happened during the event from your viewpoint?”
A. A debriefing is not a critique of the event, but a systematic review of the events that allows peers to discuss their thoughts and feelings in a safe environment.
B. This question will get the conversation started; it is easier to describe what happened before discussing the impact of the event.
C. A debriefing is not a critique of the event. Opening the conversation with what happened will help get the conversation started.
D. It is often difficult to express feelings initially because many participants have not processed the impact of this event at this stage of the debriefing. Beginning with the facts of the event can better start the conversation.
Category: Professional Issues, Nurse, Stress management (e.g., burnout,
Question 40
Which of the following is the most effective method for a nurse to reinforce a patient’s understanding of their discharge instructions?
Arrange for a follow-up phone call in 2 days to review the instructions.
Assist the patient in scheduling a follow-up appointment with their primary care provider.
Demonstrate all procedures before discharge.
Provide written instructions and make sure to verbally review them with the patient.
✓
Correct Answer
Provide written instructions and make sure to verbally review them with the patient.
A. Assisting the patient in making a follow-up appointment is important, but it will not reinforce instructions at the time of discharge.
B. Providing written discharge instructions and a discussion of the same are an effective means of reinforcing a patient’s understanding. This must be documented in the healthcare record.
C. Follow-up phone calls are an important tool for the nurse to evaluate the effectiveness of patient teaching, but these calls are not an effective reinforcement of instructions at the time of discharge.
D. Showing the patient how to do any required procedures should be included, but return demonstration by the patient will identify the need for reinforcement of instruction or additional teaching.
Category: Professional Issues, Patient, Discharge planning
Question 41
Which of the following is used in emergency departments to increase patient safety during nurses’ change-of-shift report?
Taped report
Bedside report
✓
Designated timed report
Computerized report
Correct Answer
Bedside report
A. Computerized reports do not allow for interaction of the nurses during handoff. An interactive change-of-shift report at the bedside has been proved to increase patient safety.
B. Having nurses conduct the change-of-shift report directly at the patient’s bedside has been proved to enhance patient safety and satisfaction.
C. Because of the nature of the emergency department, report during shift change is variable depending on the number of patients and the acuity of the patient assignment. Conducting the change-of-shift report at the bedside has been shown to improve patient safety and satisfaction.
D. Performing a taped report does not allow for direct interaction between the nursing staff. Conducting nurses’ change-of-shift report directly at the patient’s bedside has been shown to improve patient safety and satisfaction.
Category: Professional Issues, Patient, Patient safety
Question 42
A patient arrives by ambulance after demonstrating delusions, hallucinations, and suicidal ideation. The patient refuses all medical treatment. The nurse is aware that the healthcare team can legally treat the patient based on which type of consent?
Express consent
Involuntary consent
✓
Implied consent
Informed consent
Correct Answer
Involuntary consent
A. Express consent is given voluntarily when an individual seeks medical treatment; this type of consent is predicated on the patient’s mental capacity.
B. When an individual refuses to consent to needed medical treatment and is deemed gravely disabled or a danger to self or others, then a physician, peace officer, or licensed mental health professional can complete a certificate and petition for involuntary treatment of the patient. Documentation must include a psychiatric evaluation.
C. Implied consent is used when an individual is in a life- or limb-threatening situation and is unable to provide express consent.
D. Before a procedure, a physician describes the procedure to be performed, alternatives to the procedure, risks and benefits of the procedure, and the patient’s understanding of the procedure and its alternatives, risks, and benefits.
Category: Professional Issues, System, Patient consent for treatment
Question 43
For safety reasons, all pediatric patients should have their weight documented in which unit of measurement?
Ounces
Grains
Kilograms
✓
Pounds
Correct Answer
Kilograms
A. Weights in kilograms are safer in pediatric nursing because medications for children are ordered based on kilograms. This will reduce the incidence of both mathematical errors and medication errors.
B. A scale that measures only in kilograms is best practice for pediatric care in the emergency department. Medication doses for children are calculated by the patient’s weight in kilograms; therefore, the child should be weighed in kilograms.
C. Weights in kilograms are safer in pediatric nursing because medications for children are ordered in calculations by kilograms. This will reduce the incidence of both mathematical errors and medication errors.
D. Medication dosages for children are based on the patient’s kilogram weight, and dosages are subsequently ordered in milligrams per kilogram. Weighing all children in kilograms will reduce the incidence of both mathematical errors and medication errors.
Category: Professional Issues, System, Risk management
Question 44
A patient presents to triage with complaints of throat pain, hoarseness, and difficulty swallowing after sustaining a “clothesline” injury. Ecchymosis is noted to the anterior neck. The nurse suspects the patient may have a fractured larynx and provides appropriate instructions. Which patient action indicates appropriate understanding of the plan of care?
Requesting to lower the head of the bed flat
Communicating by writing on a piece of paper
✓
Requesting ice chips for comfort
Opening the mouth wide and protruding the tongue
Correct Answer
Communicating by writing on a piece of paper
A. The patient should be instructed not to eat or drink anything to prevent any further airway inflammation and edema. The patient may also require surgical correction of their laryngeal injury and therefore should have nothing to eat or drink until further testing is completed.
B. Resting the voice will increase the patient’s comfort and reduce swelling and inflammation to the airway.
C. This action may cause the patient to gag and result in further airway obstruction due to inflammation and edema.
D. The head of the bed should be maintained between 30 and 45 degrees to decrease edema.
Category: Respiratory Emergencies, Obstruction
Question 45
A patient with end-stage renal failure is complaining of increasing shortness of breath and exercise intolerance. The nurse auscultates muffled breath sounds and understands that the patient is at risk for developing which complication?
Metabolic alkalosis
Pleural effusion
✓
Pulmonary edema
Right ventricular hypertrophy
Correct Answer
Pleural effusion
A. Left ventricular hypertrophy is seen in end-stage renal disease caused by hypertension and atherosclerosis.
B. Patients with end-stage renal disease are more likely to present with metabolic acidosis because the kidneys are unable to eliminate enough hydrogen ions as a compensatory mechanism.
C. End-stage renal failure causes hypoalbuminemia that results from reduced syntheses of albumin. Albumin is necessary in maintaining oncotic pressure, which pulls water into the circulatory system. As albumin levels decrease, so does the oncotic pressure; this allows intravascular fluid to move out of capillaries and into the pleural space, causing a pleural effusion.
D. Pulmonary edema is the accumulation of fluid in the extravascular spaces of the lungs and is seen more frequently with acute kidney dysfunction. Also, pulmonary edema will be assessed as crackles and wheezes, as opposed to muffled breath sounds.
Category: Respiratory Emergencies, Pleural effusion
Question 46
A patient presents complaining of sudden onset of wheezing and difficulty breathing. The patient states that they sustained an acute myocardial infarction 1 month ago. On auscultation of bilateral lung fields, scattered wheezing and bibasilar crackles are heard. The patient also reports increased lower extremity swelling. Which intervention is the most appropriate?
Administer 4 mg morphine
Administer 2.5 mg albuterol via nebulizer
Administer 1000 mL 0.9% sodium chloride bolus
Administer 40 mg furosemide
✓
Correct Answer
Administer 40 mg furosemide
A. Shortness of breath with lower extremity edema may indicate heart failure in the client with recent myocardial infarction. Morphine may help lower the cardiac workload in this client; however, it is not the priority medication. Morphine has been linked with the need for ICU admission, prolonged hospitalization, and mortality.
B. Furosemide, a loop diuretic, may assist the client in heart failure by removing excess fluid from the body.
C. Albuterol may assist with opening airways, but the shortness of breath in this case is likely related to the volume overload.
D. A normal saline bolus in this situation would likely worsen the patient’s symptoms.
Category: Cardiovascular Emergencies, Heart failure
Question 47
A 34-week-pregnant female arrives complaining of dyspnea on exertion and right-sided chest pain since the previous evening. She admits to smoking a half-pack of cigarettes per day. Vital signs are BP 135/90 mm Hg, HR 125 beats/minute, RR 32 breaths/minute, SpO 85% on room air, T 37.5°C (99.5°F). 2 The nurse knows that these signs and symptoms are consistent with which of the following?
Pneumonia
Pulmonary embolism
✓
Asthma exacerbation
HELLP syndrome
Correct Answer
Pulmonary embolism
A. The signs and symptoms of pneumonia include history of illness, fever, and cough. The patient has no history of recent illness, and a mildly elevated temperature can be normal in pregnancy. The patient’s current symptoms and chief complaint are not consistent with pneumonia.
B. HELLP syndrome is a severe form of preeclampsia that occurs with hemolysis, elevated liver enzymes, and low platelets. HELLP syndrome symptoms include facial edema, headache, epigastric and right upper quadrant pain, and severely elevated BP. The patient’s chief complaint and current symptoms are not consistent with the presence of HELLP.
C. The signs and symptoms of a pulmonary embolism include dyspnea, hypoxia, feelings of anxiety, and chest pain. Risk factors for a pulmonary embolism include venous stasis, recent trauma, obesity, pregnancy, use of oral contraceptives, and a history of thrombosis.
D. The signs and symptoms of asthma include tachypnea, wheezing, anxiety, and dyspnea. The patient’s current symptoms and chief complaint are not consistent with asthma.
Category: Respiratory Emergencies, Pulmonary embolus
Question 48
The nurse is caring for a patient with apparent ligature marks on the neck. The patient is experiencing dyspnea, hoarseness, and subcutaneous emphysema in the neck and face. What is the priority intervention for this client?
Initiate humidified oxygen
✓
Set up for a chest tube
Prepare for intubation
Prepare for bronchoscopy
Correct Answer
Initiate humidified oxygen
A. Subcutaneous air may be present in a pneumothorax, which requires the insertion of a chest tube. However, this patient is exhibiting signs and symptoms of laryngeal injury.
B. Intubation can result in further injury or occlusion of the patient’s airway. The patient should be placed on high-flow oxygen; bronchoscopy should then be considered to facilitate endotracheal tube insertion, allowing for direct visualization of the vocal cords and trachea.
C. Bronchoscopy is indicated to identify any injury to the bronchus; however, the immediate priority of care for this patient is to administer high-flow oxygen.
D. Tracheobronchial injury commonly occurs as a result of penetrating trauma but could result from blunt trauma, such as a direct blow, strangulation, or clothesline-type injury. Assessment findings include dyspnea, tachypnea, hoarseness, subcutaneous emphysema in the neck, face, or upper chest, hemoptysis, and signs of airway obstruction. Interventions include maintaining the head of the bed at 30 degrees, keeping the patient NPO, delivering humidified oxygen, and maintaining the patient on vocal rest.
Category: Respiratory Emergencies, Respiratory Trauma
Question 49
A patient presents with complaints of lightheadedness, weakness, and near syncope. The patient’s 12-lead electrocardiogram reveals the presence of 2:1 atrial flutter. What is the priority intervention?
Unsynchronized cardioversion at 50 joules
Unsynchronized cardioversion at 120 joules
Synchronized cardioversion at 120 joules
Synchronized cardioversion at 50 joules
✓
Correct Answer
Synchronized cardioversion at 50 joules
A. Synchronized cardioversion is recommended for rhythms with a normal-width QRS complex. A patient with new onset of atrial flutter who is experiencing chest pain, shortness of breath, or other symptoms of instability should be considered for cardioversion. Atrial flutter requires less energy to cardiovert than other dysrhythmias.
B. Unsynchronized cardioversion (defibrillation) will result in the electrical impulse occurring randomly during the cardiac cycle, which could cause a life-threatening dysrhythmia; therefore, its use should be limited to patients who are pulseless or deteriorating.
C. Unsynchronized cardioversion (defibrillation) will result in the electrical impulse occurring randomly during the cardiac cycle, which could cause a life-threatening dysrhythmia; therefore, its use should be limited to patients who are pulseless or deteriorating.
D. Synchronized cardioversion requires less energy, with energy doses commonly between 50 and 100 joules for patients experiencing atrial flutter.
Category: Cardiovascular Emergencies, Dysrhythmias
Question 50
A 5-year-old child weighing 33 pounds (15 kg) presents to the emergency department in cardiac arrest. The child remains in ventricular tachycardia despite having been defibrillated three times, having received epinephrine 0.15 mg intraosseous (IO), and receiving good-quality cardiopulmonary resuscitation (CPR). Which drug should be administered next?
Atropine 0.3 mg
Calcium chloride 1.0 mL
Lidocaine 50 mg
Amiodarone 75 mg
✓
Correct Answer
Amiodarone 75 mg
A. Amiodarone would be the next drug used in a patient with pulseless ventricular tachycardia after defibrillation and epinephrine. Amiodarone dosing is 5 mg/kg, or 75 mg, for this patient. The patient should receive continued good-quality CPR, be reevaluated every 2 minutes, and be defibrillated as indicated.
B. Atropine is not indicted for a patient in ventricular tachycardia. Atropine is used in the treatment of symptomatic bradycardia.
C. Although calcium may be indicated for hypocalcemia, it is not considered the primary treatment for pulseless ventricular tachycardia.
D. Lidocaine may be used for the treatment of pulseless ventricular tachycardia, but administering 50 mg of lidocaine far exceeds the recommended dose of 1 mg/kg for this child.
Category: Cardiovascular Emergencies, Dysrhythmias
Question 51
A patient presents complaining of numb fingertips with throbbing pain. The fingertips of both hands are noted to be pale to light blue in color and are cool to touch. The patient denies both trauma and recent cold exposure. The patient is a two-pack-per-day smoker and has a history of hypertension. Based on the assessment findings, the nurse suspects the patient has which condition?
Raynaud’s disease
✓
Thrombocytopenia
Buerger’s disease
Inflammatory arthritis
Correct Answer
Raynaud’s disease
A. Raynaud’s disease is a blood vessel disease that affects the skin. Symptoms include numbness and pallor to the fingertips, nose, and ears. Light bluish color discoloration can also be present. Smoking, being a female, and having hypertension are noted to be predisposing factors, along with living in a cold environment.
B. Buerger’s disease, or thromboangiitis obliterans, is an uncommon peripheral vascular disease that affects the distal arms and legs. The disease decreases blood flow to the extremities, causing ischemia to the tissue.
C. Thrombocytopenia is a decrease in the number of platelets available in the blood, resulting in a high risk for both internal and external bleeding, such as epistaxis (nosebleeds). It is diagnosed with laboratory testing for a complete blood cell count.
D. Arthritis symptoms include pain and swelling in joints. Arthritis does not result in numbness of the fingertips or skin discoloration.
Category: Cardiovascular Emergencies, Peripheral vascular disease
Question 52
A patient with a history of asthma has audible wheezing, tachypnea, and pale, cool skin that persists following the administration of several albuterol nebulizer breathing treatments. What medication would the nurse anticipate giving next to this patient?
Magnesium sulfate via IV infusion
✓
Oral ibuprofen
Oral prednisolone
Aminophylline via IV infusion
Correct Answer
Magnesium sulfate via IV infusion
A. Aminophylline is rarely used except for severe exacerbations that are not relieved by bronchodilators, steroids, and magnesium.
B. Oral prednisolone is a corticosteroid that decreases inflammation in the bronchi. When a patient is having a severe asthma exacerbation, the nurse would anticipate administration of a corticosteroid such as methylprednisolone intravenously rather than orally.
C. Magnesium sulfate inhibits calcium influx into airway smooth muscle cells, thus allowing for bronchodilation. Magnesium sulfate is used in the treatment of acute severe asthma exacerbations for patients who are not responsive to conventional treatments.
D. Ibuprofen is a nonsteroidal anti-inflammatory that has no indication in the treatment of acute asthma.
Category: Respiratory Emergencies, Asthma
Question 53
A toddler presents to triage with family members. The child is diaphoretic and sitting in a tripod position with drooling and audible stridor. The parent states that the child was playing when they suddenly heard the child coughing. The family member denies recent illness or ill contacts, past medical history is negative for similar episodes or chronic illnesses, and immunizations are up to date. What is the most likely disorder this child is experiencing?
Acute laryngotracheobronchitis (croup)
Acute epiglottitis
Acute asthma exacerbation
Foreign body aspiration
✓
Correct Answer
Foreign body aspiration
A. The family member does not report any recent illness or recent ill contacts. The history of events and assessment findings are consistent with a foreign body aspiration. Patients who have ingested a foreign body will present with a variety of symptoms that include coughing, apnea, wheezing, drooling, and stridor. Airway management is the priority intervention for this patient.
B. The family member does not report any past medical history for the patient. Drooling is not an assessment finding with an asthmatic attack, and asthma symptoms would include wheezing, which is not present in this patient.
C. The family member does not report any recent illness or ill contacts. The current history of events and assessment findings are consistent with foreign body aspiration.
D. In croup, children typically experience a characteristic seal-bark cough that can be accompanied by a fever. In this case, there is no recent illness, and the child does not have a seal-bark cough.
Category: Respiratory Emergencies, Obstruction
Question 54
A tension pneumothorax leading to inadequate tissue perfusion is considered which type of shock?
Hypovolemic
Distributive
Cardiogenic
Obstructive
✓
Correct Answer
Obstructive
A. The increasing intrathoracic pressure of a tension pneumothorax results in compression of the lungs, heart, and great vessels. Venous return decreases and cardiac output becomes inadequate, resulting in obstructive shock.
B. Hypovolemic shock is caused by an insufficient amount of circulating blood and would not be caused by a tension pneumothorax.
C. Distributive shock is caused by an abnormal distribution of intravascular volume and would not be caused by a tension pneumothorax.
D. Although a tension pneumothorax causes decreased cardiac output, it is the result of insufficient venous blood return, not the failed ability of the myocardial pump. Therefore, it would be classified as obstructive shock, not cardiogenic shock.
Category: Respiratory Emergencies, Pneumothorax
Question 55
Which disease process is characterized by the presence of foreign material occluding one or more pulmonary blood vessels?
Pneumothorax
Pulmonary edema
Pulmonary embolism
✓
Pleural effusion
Correct Answer
Pulmonary embolism
A. Pulmonary embolism is defined as the presence of foreign material occluding one or more pulmonary blood vessels. The signs and symptoms of a pulmonary embolism include dyspnea, hypoxia, feelings of anxiety, and chest pain. Risk factors for a pulmonary embolism include venous stasis, recent trauma, obesity, pregnancy, use of oral contraceptives, and a history of thrombosis.
B. Pulmonary edema is characterized by the accumulation of fluid in the alveoli and interstitial space that inhibits the exchange of oxygen and carbon dioxide and leads to tissue hypoxia. Pulmonary embolism is defined as the presence of foreign material occluding one or more pulmonary blood vessels.
C. Pneumothorax occurs when there is an accumulation of air in the pleural space. As the air and pressure within the pleural cavity increase, a partial or complete collapse of the lung results. Pulmonary embolism is described as the presence of foreign material occluding one or more pulmonary blood vessels.
D. A pleural effusion is the abnormal collection of fluid in the pleural space. Symptoms of an effusion include chest pain, dyspnea, and a dry, nonproductive cough. Pulmonary embolism is defined as the presence of foreign material occluding one or more pulmonary blood vessels.
Category: Respiratory Emergencies, Pulmonary embolus
Question 56
Which condition places a patient at the highest risk for infective endocarditis following a dental procedure?
Diabetes
Congestive heart failure
Prosthetic cardiac valve
✓
Rheumatoid arthritis
Correct Answer
Prosthetic cardiac valve
A. To reduce the incidence of infective endocarditis, it is recommended that patients with prosthetic valves, a previous history of infective endocarditis, or congenital heart disease receive antibiotic prophylaxis before dental procedures. Dental procedures that place this high-risk group of patients at risk for infective endocarditis include manipulation of gingival tissue, periapical region of the teeth, or perforation of the oral mucosa (Class IIa recommendation).
B. Diabetes is not considered a high-risk condition for endocarditis.
C. Congestive heart failure is not considered a high-risk condition for endocarditis.
D. Rheumatoid arthritis is not considered a high-risk condition for endocarditis.
Category: Cardiovascular Emergencies, Endocarditis
Question 57
A patient arrives via emergency medical services with chest pain, a low-grade fever of 37.9°C (100.2°F), cough, shortness of breath, and a 1–3 mm ST-segment elevation on their 12-lead electrocardiogram in all leads except aVR and V1. The nurse recognizes that the patient’s symptoms are associated with the presence of:
congestive heart failure.
acute coronary syndrome.
pericarditis.
✓
ST-segment elevation myocardial infarction.
Correct Answer
pericarditis.
A. Shortness of breath and cough alone do not indicate the presence of congestive heart failure.
B. ST-segment elevation in all leads except aVR and V1 is indicative of pericarditis.
C. Fever, chest pain, shortness of breath, and ST-segment elevation in all leads except aVR and V1 are indicative of pericarditis.
D. The patient’s symptoms of fever, chest pain, and shortness of breath are not consistent with acute coronary syndrome.
Category: Cardiovascular Emergencies, Pericarditis
Question 58
A patient with no past medical history arrives to triage with a complaint of chest pain, fever, malaise, and a productive cough. The nurse notes unilateral crackles on auscultation of the lungs. What will this patient most likely be treated for?
Acute bronchitis
Community-acquired pneumonia
✓
Chronic obstructive pulmonary disease
Acute asthma
Correct Answer
Community-acquired pneumonia
A. This patient has no past medical history noted. Patients with chronic obstructive pulmonary disease have causative factors in developing this disease, such as smoking, environmental pollution, occupational exposure, and heredity.
B. Although acute bronchitis can produce fever, cough, and malaise, adventitious breath sounds in a person with acute bronchitis will clear when the patient coughs.
C. A person with asthma is more likely to have wheezing on auscultation, and dyspnea, cough, and restlessness. This patient has no history of asthma.
D. This patient meets the clinical diagnostic criteria for pneumonia, with chest pain, fever, malaise, productive cough, and unilateral crackles on auscultation.
Category: Respiratory Emergencies, Infections
Question 59
A patient presents with a complaint of sudden onset of right lower leg pain. The patient reports that they were recently discharged from the hospital following a 3-week hospitalization for a right femur fracture with internal fixator repair. The nurse notes swelling and redness to the right calf. The nurse realizes that the patient is exhibiting signs and symptoms of what disorder?
Phlebitis of the right leg
Compartment syndrome
Deep vein thrombosis
✓
Postoperative infection
Correct Answer
Deep vein thrombosis
A. Phlebitis is associated with superficial veins. Given the history of this patient, phlebitis is not likely.
B. The patient reports redness and swelling to the calf, which is not the site of the surgical intervention. The leg is not warm to touch, which would indicate a possible infection.
C. Swelling, pain, and redness, as well as a recent fracture with an extended period of immobilization, indicate that the patient is most likely exhibiting signs of a deep vein thrombosis.
D. Compartment syndrome occurs 6–8 hours—and in some cases up to 96 hours—after the injury has occurred. This patient’s injury occurred more than 3 weeks earlier. Compartment syndrome is associated with closed traumatic injuries. Because the injury for this patient was a femur fracture, compartment syndrome of the calf is unlikely.
Category: Cardiovascular Emergencies, Thromboembolic disease (e.g., deep vein
Question 60
Which of the following findings is the best indicator of high-quality cardiopulmonary resuscitation (CPR)?
A decrease of skin and mucous membrane cyanosis
An increasing end-tidal carbon dioxide level
✓
A compression depth of 1.5 inches
Palpable pulses with the performance of chest compressions
Correct Answer
An increasing end-tidal carbon dioxide level
A. High-performance CPR requires compression depth of 1.5 to 2 inches for optimal outcomes.
B. Pulses should be palpable during effective CPR, but this is not the best indicator of high-quality CPR.
C. Cyanosis is the result of poor tissue oxygenation. An improvement in tissue color may indicate improvement in end-organ perfusion but is not the best indicator of effective CPR.
D. An increasing end-tidal carbon dioxide level indicates increasing cellular perfusion with effective CPR or return of spontaneous circulation.
Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 61
What is the definition of preload?
Systolic blood pressure
End diastolic volume
✓
Mean arterial pressure (MAP)
End systolic volume
Correct Answer
End diastolic volume
A. Preload is the stretch the heart must perform to accept blood before contraction of the heart chambers. End systolic volume is the volume of blood following systole or contraction and is influenced by contractility and affected by afterload.
B. Preload is the amount of blood within the left ventricle at the end of diastole, or left ventricular end diastolic pressure. The amount of blood within the ventricle at the end of diastole is related to venous return, total blood volume, and “atrial kick.”
C. Systolic blood pressure represents the ventricular volume of blood ejected and the response to the blood ejected by the arterial system.
D. MAP represents the body’s perfusion pressure and is calculated by adding the systolic blood pressure to twice the diastolic pressure and dividing that number by 3. Preload is the amount of blood within the left ventricle at the end of diastole. The amount of blood within the ventricle at the end of diastole is related to venous return, total blood volume, and “atrial kick.”
Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock
Question 62
An anxious patient with a history of coronary artery disease (CAD) arrives by ambulance following an acute onset of difficulty breathing. The patient is diaphoretic and denies chest pain. High-flow oxygen by nonrebreather mask has been applied. Vital signs are BP 210/140 mm Hg, HR 130 beats/minute, RR 32 breaths/minute, SpO 88%. In addition to initiating noninvasive ventilation to treat 2 the patient’s difficulty breathing, the nurse anticipates the administration of which medication to further treat the patient’s symptoms?
Acetylsalicylic acid orally
Nitroglycerin (NTG) infusion
✓
Morphine intravenously
Furosemide intravenously
Correct Answer
Nitroglycerin (NTG) infusion
A. Morphine (morphine sulfate) is used in heart failure to reduce preload, decrease afterload, decrease anxiety, and reduce sympathetic activation to decrease heart rate. However, morphine should be avoided in acutely dyspneic patients in acute heart failure.
B. Loop diuretics are indicated in fluid volume overload. However, loop diuretics such as furosemide are not necessarily indicated in acute pulmonary edema unless there is evidence of fluid volume overload.
C. Patients who present with acute pulmonary edema are typically markedly hypertensive and in acute respiratory distress. Immediate interventions should focus on reduction of afterload and preload, as well as respiratory support. NTG is the most important first-line medication in the treatment of acute pulmonary edema and respiratory distress. The initiation of a continuous NTG infusion at low doses acts as a vasodilator, leading to decreased preload; at higher doses (> 100 mcg/minute), it acts as a potent afterload reducer.
D. Although acetylsalicylic acid (aspirin) may have a role in this patient if acute coronary syndrome or acute myocardial infarction is suspected or confirmed, it provides no immediate effect in the treatment of acute pulmonary edema to reduce afterload.
Category: Cardiovascular Emergencies, Heart failure
Question 63
Which of the following is a form of distributive shock?
Cardiogenic
Obstructive
Neurogenic
✓
Hypovolemic
Correct Answer
Neurogenic
A. Distributive shock occurs as a result of maldistribution of volume. In neurogenic shock, this occurs because of a loss of autonomic sympathetic vasomotor regulation while parasympathetic responses are uncontested. Other forms of distributive shock include anaphylactic and septic shock.
B. Distributive shock occurs as a result of maldistribution of volume. Cardiogenic shock occurs when there is a malfunction of the pump.
C. Distributive shock occurs as a result of maldistribution of volume. Hypovolemic shock results from significant fluid loss, such as that from bleeding, vomiting, or diarrhea.
D. Distributive shock occurs as a result of maldistribution of volume. Obstructive shock results from inadequate circulating volume due to the presence of pulmonary embolus, pericardial tamponade, or a tension pneumothorax.
Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock
Question 64
A patient with a known history of alcohol abuse was found lying on the sidewalk and brought to the emergency department. The patient is agitated and confused, speech is slurred, and there is a strong smell of alcohol on the patient’s breath. After placing the patient in a treatment area, what is the next action performed by the emergency nurse?
Request a blood alcohol level to be drawn
Begin the process for referral to a detoxification unit
Assess for the risk of violence toward self or others
✓
Initiate an infusion of a thiamine-containing solution
Correct Answer
Assess for the risk of violence toward self or others
A. When a patient with a substance or alcohol disorder presents to the ED for treatment, begin assessing the patient for risk of violence for the safety of the patient and the staff. Recognize that the patient’s altered mental status must be a factor in determining the patient’s immediate need for care as well.
B. The patient’s altered mental status must drive the triage decision. Although a blood alcohol level test may be indicated, the patient should first be assessed to determine other possible, more serious etiologies for a confused mental state.
C. A lack of thiamine (vitamin B ) is common in patients with alcoholism. The 1 deficiency can result in encephalopathy and damage to the areas of the brain that control memory. The etiology of the patient’s change in mental status must be determined before any treatment decisions are made. If it is decided that the patient’s confusion is due to alcohol abuse, then an IV containing thiamine would be appropriate.
D. The priority of care for this patient is understanding the etiology of the altered mental status change. A referral to a detoxification unit may be indicated if alcohol abuse is found to be the basis of the patient’s confusion, but that cannot be determined until more serious etiologies, such as head trauma, stroke, hyperglycemia, or seizure disorder, have been ruled out.
Category: Professional Issues, Nurse, Ethical dilemmas
Question 65
Your patient is taking isoniazid and rifampin for tuberculosis. Which physical finding should the nurse assess for that is a potential side effect from medications?
Patient reports having diarrhea.
Stools are black colored.
Patient reports the presence of tinnitus.
Urine is orange colored.
✓
Correct Answer
Urine is orange colored.
A. Rifampin is a medication used for tuberculosis and has a side effect of causing an orange discoloration of all body fluids (urine, sputum, tears, sweat).
B. Patients taking these medications can present with clay-colored stools, not black-colored.
C. Diarrhea is not a common complication of the medications typically used as part of the multidrug regimen for tuberculosis.
D. Tinnitus (ringing in the ears) is not a common complication of the medications typically used as part of the multidrug regimen for tuberculosis. It is a side effect of high doses of nonsteroidal anti-inflammatories.
Category: Environment and Toxicology Emergencies, and Communicable
Question 66
Following the death of a patient in the emergency department, who determines if the patient’s organs and tissues are suitable for donation?
Patient’s legal next-of-kin
Local medical examiner
Emergency physician
Organ procurement organization
✓
Correct Answer
Organ procurement organization
A. In compliance with state and local regulations, the medical examiner must be notified of any death that occurs in the emergency department. In some cases, law enforcement protocols must be followed, but the representative of the organ procurement organization, not the medical examiner, determines the patient’s suitability for organ donation.
B. A representative from the organ procurement organization is responsible for determining if the patient’s organs are suitable for donation; the emergency department physician cannot make this determination.
C. In 1998, the U.S. Department of Health and Human Services ruled that hospitals must notify their organ procurement organization of any patient who dies in their hospital or whose death is imminent.
D. The patient’s legal next-of-kin must provide consent for donation, but it is the responsibility of the representative from the hospital’s designated organ procurement organization to determine if the organs and tissues are suitable for donation.
Category: Professional Issues, Patient, End-of-life and palliative care (e.g., organ and
Question 67
According to the Federal Emergency Management Agency, there are five mission areas of emergency response. The five phases are prevention, protection, response, recovery, and:
evacuation.
mitigation.
✓
education.
management.
Correct Answer
mitigation.
A. Education is an important part of disaster management and includes educating personnel, administration, and the public for everyone’s safety. However, education is performed throughout all four phases of disaster management: mitigation, preparedness, response, and recovery.
B. Managing the situation is the responsibility of leaders before, during, and after a mass casualty or disaster event. This is done throughout the five phases of emergency management, mitigation, preparedness, response, and recovery.
C. Evacuation is removing people and animals from an incident to protect them from danger. This is done during a mass casualty or disaster event and is part of the response phase of disaster management.
D. Mitigation is preventing future emergencies or minimizing their effects. According to the Federal Emergency Management Agency, this is an important step in emergency management. Mitigation happens both before and after a disaster. Buying flood and fire insurance for your home is an example of mitigation.
Category: Professional Issues, System, Disaster management
Question 68
You receive a phone call from an individual who is seeking medical advice for their abdominal pain. What is the appropriate response for the emergency nurse to give to this patient?
“It is very busy here right now; I think you should just wait and be seen by your physician tomorrow.”
“It sounds like you have a viral infection. Be sure to increase your fluids and avoid dairy products.”
“I am sorry I cannot answer your question over the phone. We are available 24 hours a day and would be happy to evaluate you in person if you wish to be seen.”
✓
“I will call you back after I speak to the emergency provider. Can you tell me more about the pain that you are experiencing?”
Correct Answer
“I am sorry I cannot answer your question over the phone. We are available 24 hours a day and would be happy to evaluate you in person if you wish to be seen.”
A. The emergency nurse should not provide any medical advice over the phone unless the facility has a designated telephone triage program, and the nurse has completed the appropriate education for this program. Telephone advice given by some emergency departments is not standardized and may be inadequate to the point of jeopardizing the welfare of the caller.
B. It is inappropriate for the nurse to provide any medical advice over the phone to a potential patient; this would not be an appropriate answer. Telephone advice given by some emergency departments is not standardized and may be inadequate to the point of jeopardizing the welfare of the caller.
C. The nurse cannot make an assessment over the phone; the patient should be advised to come to the emergency department for an evaluation. Telephone advice given by some emergency departments is not standardized and may be inadequate to the point of jeopardizing the welfare of the caller.
D. Unless a hospital is equipped with a formal telephone triage system, patients should be advised that they can come to the emergency department to be properly evaluated or call emergency medical services to transport them.
Category: Professional Issues, Triage
Question 69
When caring for a patient who has experienced an act of interpersonal violence, it is important that the nurse perform which of the following?
Recognize items that may have forensic value
✓
Label bullet wounds as “entrance” and “exit”
Use only fluorescent lights when photographing injuries
Document patient statements using proper medical terminology
Correct Answer
Recognize items that may have forensic value
A. Fluorescent lights may give bruises a yellow or green tint when photographed. The nurse should photograph these injuries using several different light sources.
B. When documenting the patient’s report of the events, best practice is to directly quote the patient using the patient’s words, placed within quotation marks, rather than proper medical terminology. This supports the documentation as an accurate and unbiased report of the patient’s statements.
C. Differentiating between entrance and exit wounds of a projectile is beyond the education and training of the emergency nurse. Wounds should be identified by their anatomical location.
D. Stabilization of the patient’s physical condition is always the nurse’s priority, but because the nurse may have contact with the patient before law enforcement is involved, it becomes the nurse’s responsibility to recognize, properly collect, and store evidence with potential forensic value.
Category: Professional Issues, Patient, Forensic evidence collection
Question 70
Nursing staff in the emergency department voice a concern that blood culture contamination rates are high. What is the initial step the nurses should complete to develop a new, evidence-based blood-drawing protocol?
Identify patient preferences and values
Develop the clinical question
✓
Evaluate the hierarchy of evidence
Collect the evidence
Correct Answer
Develop the clinical question
A. Collecting the evidence is accomplished through a review of the literature. This review provides the foundation of the best evidence available to address the clinical question; therefore, the initial step is to define the problem.
B. Defining the problem in the form of a clinical question provides direction for the remainder of the research and protocol development process.
C. Evidence must be evaluated to determine if it is valid, reliable, and applicable to the nurses’ hospital setting and emergency department population.
D. Once the evidence has been collected and evaluated, personal clinical expertise and patient preferences and values are incorporated into the development of the new, evidence-based protocol.
Category: Professional Issues, Nurse, Evidence-based practice
Question 71
Hospital staff who access the medical record of a patient whom they have no responsibility to care for would be in violation of which federal regulation?
Emergency Medical Treatment and Active Labor Act
Advance Directives
Notifiable Diseases and Conditions
Health Insurance Portability and Accountability Act
✓
Correct Answer
Health Insurance Portability and Accountability Act
A. Notifiable diseases and conditions include errors in assessment or implementation of patient conditions; failure to act as a patient advocate; falls; medication errors; and unsafe or malfunctioning equipment. Reportable conditions are governed by state laws and require breach of patient confidentiality for the reporting of these types of events.
B. Emergency Medical Treatment and Active Labor Act regulations are enforced to ensure that any patient asking for treatment is given a medical screening and any life-stabilizing treatment regardless of their ability to pay.
C. The Health Insurance Portability and Accountability Act’s privacy regulations protect personal health information and require that the information only be accessed by authorized entities, such as healthcare providers, who are involved in the planning and care of the patient.
D. Advance directives involve a federal law that requires hospitalized patients to be provided with information regarding written statements to healthcare providers about treatment choices if a terminal or irreversible illness occurs.
Category: Professional Issues, System, Federal regulations (e.g., HIPAA, EMTALA)
Question 72
The emergency department nurse is preparing to administer tissue plasminogen activator to a stroke patient. What percentage of the total dose should the nurse first administer to this patient as a bolus dose?
5%
15%
1%
10%
✓
Correct Answer
10%
A. 10% of the 0.9 mg/kg total dose is administered as a bolus over 1 minute. The remaining 90% of the 0.9 mg/kg dose is then administered over 60 minutes.
B. 10% of the 0.9 mg/kg total dose is administered as a bolus over 1 minute. The remaining 90% of the 0.9 mg/kg dose is then administered over 60 minutes.
C. 10% of the 0.9 mg/kg total dose is administered as a bolus over 1 minute. The remaining 90% of the 0.9 mg/kg dose is then administered over 60 minutes.
D. 10% of the 0.9 mg/kg total dose is administered as a bolus over 1 minute. The remaining 90% of the 0.9 mg/kg dose is then administered over 60 minutes.
Category: Neurological Emergencies, Stroke
Question 73
On arrival to triage, a patient states they have experienced facial numbness and slurred speech, although the symptoms disappeared just before arrival. The patient states that they no longer wish to be seen by the emergency provider. Which of the following is the priority intervention for this patient?
Inform the patient that they must be seen because of EMTALA regulations
Perform a screening evaluation to rule out a stroke
Explain to the patient why their symptoms should be evaluated now
✓
Obtain a blood sample to check for hypoglycemia
Correct Answer
Explain to the patient why their symptoms should be evaluated now
A. Mentally competent adults have the right to control decisions related to their health care. This patient most likely suffered a transient ischemic attack, but there may be another reason for their symptoms. Even though this patient’s symptoms have resolved, they could return. The provider will evaluate for the presence of associated risk factors and recommend appropriate follow-up care.
B. The patient is asymptomatic. Obtaining a blood sugar measurement is useful, but not the priority for this patient. The patient first needs to consent to being evaluated.
C. The patient is asymptomatic. Performing a stroke screen is important, but the patient first must consent to being evaluated.
D. EMTALA does not apply here because it is the patient’s decision to leave. However, approximately 10–20% of patients with transient ischemic attack could go on to have a CVA; therefore, the patient should be encouraged to remain for evaluation by a provider.
Category: Neurological Emergencies, Transient ischemic attack (TIA)
Question 74
A patient has been receiving an intravenous infusion of norepinephrine for the treatment of hypotension related to the presence of neurogenic shock following a fracture of thoracic vertebrae 4 and accompanying spinal cord injury. Which of the following clinical signs would suggest that this intervention has had the desired effect?
Urine output of 20 mL/hour and 25 mL/hour over each of the past 2 hours
Systolic blood pressure of 100 mm Hg
✓
Capillary refill time of 4 seconds
The patient becoming less responsive
Correct Answer
Systolic blood pressure of 100 mm Hg
A. The patient’s level of consciousness is an indication of cerebral perfusion. With the resolution of hypovolemic shock and improvement in blood pressure, the patient’s level of consciousness should either remain the same or improve, but the patient should not become less responsive.
B. Prolonged capillary refill time is an indicator of tissue perfusion, but it can be affected by a variety of factors. For this reason, capillary refill is not considered a reliable indicator of shock resolution.
C. Hypotension and bradycardia are suggestive of neurogenic shock. Patients who have sustained a spinal cord injury resulting in sympathetic input experience no motor function, no sensation, and a loss of reflexes below the level of the spinal cord injury. A systolic BP greater than 90 mm Hg is a recognized end-point of shock resuscitation.
D. Urine output of less than 30 mL/hour is an indication of impaired renal perfusion. Urine output of greater than or equal to 30 mL/hour is considered the end-point of shock resuscitation.
Category: Neurological Emergencies, Head and spinal cord trauma
Question 75
Which of the following radiologic findings best describes the presence of a Le Fort II fracture?
A transverse maxillary bone fracture occurring above the level of the teeth
A complete craniofacial separation, including the maxilla, zygoma, and orbits
A pyramidal maxillary bone fracture involving the midface
✓
A fracture of any of the five bones in the base of the skull
Correct Answer
A pyramidal maxillary bone fracture involving the midface
A. There are three types of Le Fort fractures. A Le Fort II fracture is a pyramidal maxillary bone fracture involving the midface that traverses above the bridge of the nose. A Le Fort I fracture is a transverse maxillary bone fracture occurring above the level of the teeth, causing separation of the teeth from the maxilla. A Le Fort III fracture is a complete craniofacial separation, including the maxilla, zygoma, and orbits. A fracture of the base of the skull resulting in cerebrospinal fluid leakage is a basilar skull fracture.
B. There are three types of Le Fort fractures. A Le Fort I fracture is a transverse maxillary bone fracture occurring above the level of the teeth, causing separation of the teeth from the maxilla. A Le Fort II fracture is a pyramidal maxillary bone fracture involving the midface that traverses above the bridge of the nose. A Le Fort III fracture is a complete craniofacial separation, including the maxilla, zygoma, and orbits. A fracture of the base of the skull resulting in cerebrospinal fluid leakage is a basilar skull fracture.
C. There are three types of Le Fort fractures. A Le Fort III fracture is a complete craniofacial separation, including the maxilla, zygoma, and orbits. A Le Fort I fracture is a transverse maxillary bone fracture occurring above the level of the teeth, causing separation of the teeth from the maxilla. A Le Fort II fracture is a pyramidal maxillary bone fracture involving the midface that traverses above the bridge of the nose. A fracture of the base of the skull resulting in cerebrospinal fluid leakage is a basilar skull fracture.
D. A fracture of the base of the skull resulting in cerebrospinal fluid leakage is a basilar skull fracture.
Category: Neurological Emergencies, Head and spinal cord trauma
Question 76
The emergency nurse is caring for a patient with a subdural hematoma. Which of the following assessment findings would indicate the presence of an early increase in intracranial pressure?
Bradycardia
Headache
✓
Decreased respiratory effort
Dilated, nonreactive pupils
Correct Answer
Headache
A. Early assessment findings of increased intracranial pressure include headache, nausea, vomiting, amnesia, behavioral changes, and an altered level of consciousness. As pressure continues to rise, later signs and symptoms include dilated, nonreactive pupils, unresponsiveness, abnormal motor posturing, and Cushing’s triad (widening pulse pressure, reflex bradycardia, and a decreased respiratory effort).
B. Early assessment findings of increased intracranial pressure include headache, nausea, vomiting, amnesia, behavioral changes, and an altered level of consciousness.
C. Early assessment findings of increased intracranial pressure include headache, nausea, vomiting, amnesia, behavioral changes, and an altered level of consciousness. As pressure continues to rise, later signs and symptoms include dilated, nonreactive pupils, unresponsiveness, abnormal motor posturing, and Cushing’s triad (widening pulse pressure, reflex bradycardia, and a decreased respiratory effort).
D. Increased intracranial pressure includes predictable and chronological signs and symptoms. Early assessment findings of increased intracranial pressure include headache, nausea, vomiting, amnesia, behavioral changes, and an altered level of consciousness. As pressure continues to rise, later signs and symptoms include dilated, nonreactive pupils, unresponsiveness, abnormal motor posturing, and Cushing’s triad (widening pulse pressure, reflex bradycardia, and a decreased respiratory effort).
Category: Neurological Emergencies, Increased intracranial pressure (ICP)
Question 77
A patient arrives by ambulance unresponsive after falling off a bicycle. The patient was not wearing a helmet at the time of injury. Cervical spine immobilization is in place. During the primary assessment, the nurse observes loose teeth and vomitus in the mouth. To properly suction the patient, the emergency nurse should perform which action?
Place the patient in the “sniffing position” with neck and chin extended
Open the airway using the head tilt–chin lift maneuver
Insert an appropriately sized nasopharyngeal airway
Open the airway using the jaw-thrust maneuver
✓
Correct Answer
Open the airway using the jaw-thrust maneuver
A. When a cervical spine injury is suspected, the jaw-thrust maneuver is the safest method to use in order to maintain cervical spine protection while a second person is suctioning the airway.
B. The head tilt–chin lift maneuver should never be used to open the airway in a patient with suspected cervical trauma because the use of this maneuver can result in further damage to the cervical spine in patients with a spinal injury.
C. The insertion of a nasopharyngeal airway is contraindicated in patients with suspected facial trauma or basilar skull fractures.
D. The sniffing position is contraindicated when cervical spine immobilization must be maintained. The sniffing position in patients with a suspected cervical spine injury can lead to further injury to the spine.
Category: Respiratory Emergencies, Obstruction
Question 78
An older adult presents for evaluation of ataxia, headache, and vomiting. The family reports that the patient sustained a fall 2 days ago and struck their head. The nurse suspects this patient may have experienced which of the following?
Subdural hematoma
✓
Subarachnoid hemorrhage
Intraparenchymal hemorrhage
Epidural hematoma
Correct Answer
Subdural hematoma
A. Intraparenchymal hemorrhage usually results from a spontaneous small-vessel rupture associated with uncontrolled hypertension.
B. An epidural hematoma results most commonly from injury to the middle meningeal artery. It may be caused by a blow to the side of the head, in the temporal region. Symptoms are rapid and sometimes accompanied by a brief period of lucidity, followed by a rapid deterioration in level of consciousness.
C. Subdural hematomas result from injury to the bridging veins. Older adults and chronic alcoholic patients are at increased risk because of brain atrophy. Symptom onset is typically slow and progressive, over 2 or more days, but can also begin within 48 hours if the patient receives a blow to the head or is anticoagulated.
D. Most subarachnoid hemorrhages develop from rupture of cerebral artery aneurysms commonly referred to as a berry aneurysm. However, the classic symptomatology is the patient’s complaint of a sudden onset of “the worst headache of my life.”
Category: Neurological Emergencies, Neurogenic shock
Question 79
The emergency nurse is caring for a patient who received procedural sedation. Which of the following would delay discharge for this patient?
The patient ambulates with assistance.
The patient needs help getting dressed.
The patient lives alone.
✓
The patient has mild pain.
Correct Answer
The patient lives alone.
A. The patient may continue to have some pain postprocedure. As long as it is mild and can be controlled, discharge does not need to be delayed.
B. The patient may be a little clumsy after sedation and need some assistance in getting dressed, but they can be discharged as long as they have someone to help them at home.
C. Patients who have received procedural sedation need a responsible person to provide supervision at home for several hours. If there is no one available, they should be kept in the ED or admitted.
D. The patient may need a little assistance with ambulation because of lightheadedness postsedation, but it should not delay discharge.
Category: Professional Issues, Patient, Pain management and procedural sedation
Question 80
The emergency nurse is caring for a 10-year-old trauma patient who is unresponsive and hemodynamically unstable because of severe internal hemorrhage. The trauma surgeon has ordered that the massive transfusion protocol (MTP) be initiated for this patient. The family is refusing the blood transfusion because of their religious beliefs. The nurse should plan to:
ask the family to sign a Do Not Resuscitate form.
initiate the transfusion protocol.
✓
complete an incident report for not initiating the transfusion protocol.
provide comfort measures only.
Correct Answer
initiate the transfusion protocol.
A. In the event that a child presents and the family refuses essential medical care, protective custody of the child is indicated to allow necessary treatment to be initiated. Adults have autonomous rights, but they cannot be imposed on a child.
B. In the event that a child presents and the family refuses essential medical care, protective custody of the child is indicated to allow necessary treatment to be initiated. Adults have autonomous rights, but they cannot be imposed on a child.
C. In the event that a child presents and the family refuses essential medical care, protective custody of the child is indicated to allow necessary treatment. Adults have autonomous rights, but they cannot be imposed on a child.
D. In the event that a severely injured or ill child presents and the family refuses essential medical care, protective custody of the child is indicated to allow the necessary treatment to be initiated. Adults have autonomous rights, but they cannot be imposed on a child.
Category: Professional Issues, Patient, Cultural considerations (e.g., interpretive
Question 81
The emergency department is notified that a patient will soon be arriving via emergency medical services. The patient was involved in a possible shooting, and the police are requesting that the patient’s hands be “bagged.” The emergency nurse is aware that the police are requesting that which of the following actions be performed when the patient arrives?
Place a clear plastic bag over each hand and secure at the wrist
Place a paper bag over each hand and secure at the wrist
✓
Place a towel over each hand and secure at the wrist
Place a sterile drape over each hand and secure at the wrist
Correct Answer
Place a paper bag over each hand and secure at the wrist
A. A sterile drape is not required; each hand should be bagged with an individual paper bag and sealed at the wrist until police can arrive to assess the hands for evidence.
B. Plastic bags can harbor moisture and may alter the evidence. Each hand should be bagged with an individual paper bag and sealed at the wrist until police can arrive to assess the hands for evidence.
C. Place a paper bag over each hand and seal at the wrist with tape. Police will need to assess the hands for gunpowder residue testing and for evidence under the nails or on the hands.
D. Towels can harbor moisture, and key evidence could be removed by the towel, especially if the hand has open wounds. Each hand should be bagged with an individual paper bag and sealed at the wrist until police can arrive to assess the hands for evidence.
Category: Professional Issues, Patient, Forensic evidence collection
Question 82
A patient arrives via emergency medical services after sustaining a gunshot wound to the back. On assessment, the patient can move their right leg but cannot feel pain or touch. They are unable to move their left leg but can feel pain and touch. The nurse is aware that this assessment finding is consistent with which of the following spinal cord syndromes?
Anterior cord syndrome
Cauda equina syndrome
Central cord syndrome
Brown–Séquard syndrome
✓
Correct Answer
Brown–Séquard syndrome
A. Central cord syndrome results from injury to the central portion of the cord and results in motor and sensory deficits being more pronounced in the upper extremities than in the lower extremities.
B. Cauda equina syndrome results from lumbosacral nerve root compression. The patient will experience varying degrees of motor and sensory loss in the lower extremities, as well as bladder and/or bowel dysfunction.
C. Brown–Séquard syndrome is an incomplete spinal cord injury, usually the result of penetrating trauma. It is characterized by the patient experiencing an ipsilateral (same side as the lesion) decrease in motor function with intact sensation and a contralateral (opposite side) decrease in sensation with intact motor function.
D. Anterior cord syndrome results from injury to the frontal portion of the cord and causes loss of motor function, and pain and temperature perception below the level of the injury. The patient is still able to sense vibration, touch, pressure, and proprioception because the posterior column of the cord has remained intact.
Category: Neurological Emergencies, Head and spinal cord trauma
Question 83
What is the primary reason patients with chronic obstructive pulmonary disease (COPD) should receive the influenza vaccine?
It will prevent the need for long-acting beta agonists.
Bacterial infections play a major role in COPD exacerbations.
It will prevent them from acquiring influenza.
Viral infections play a major role in COPD exacerbations.
✓
Correct Answer
Viral infections play a major role in COPD exacerbations.
A. Bacterial infections do play a major role in COPD exacerbations, but the influenza vaccine will not have any effect on bacterial infections. The pneumococcal vaccine helps protect patients against bacterial infections.
B. Long-acting beta agonists are used for the treatment of COPD, but receiving the vaccine will not reduce the need for long-acting beta agonists.
C. Patients can still get influenza even if they receive the vaccine. Several organisms that are not a part of the vaccine can still cause disease, though symptoms tend to be less severe.
D. This is a preventive measure to help reduce morbidity and mortality in patients with COPD. Patients with COPD should be educated on medication compliance that includes the use of inhalers and nebulizers, as well as the need to receive influenza immunizations.
Category: Respiratory Emergencies, Infections
Question 84
Which change in the patient’s condition would indicate to the nurse that the treatment for acute alcohol withdrawal is having its intended effect?
Increased temperature
Brisk pupil reaction
Increased motor activity
Decreased blood pressure
✓
Correct Answer
Decreased blood pressure
A. Alteration in pupil reaction time to light is not an expected finding in alcohol withdrawal.
B. Early withdrawal symptoms include tachycardia, palpitations, hypertension, hyperthermia, diaphoresis, headache, and tremors. A decreased blood pressure is a positive effect from the initiation of treatment for alcohol withdrawal.
C. A low-grade fever may accompany alcohol withdrawal. An intended effect of treatment would be to decrease the patient’s temperature.
D. Tremulousness and motor hyperactivity can occur in alcohol withdrawal. The goal would be to decrease motor activity and the presence of tremors.
Category: Medical Emergencies, Withdrawal syndrome
Question 85
A patient presents after taking an overdose of a beta blocker medication. Which of the following signs and/or symptoms indicate that the treatment has been effective?
Decreasing heart rate
Decreasing level of consciousness
Increasing glucose level
✓
Lowering blood pressure
Correct Answer
Increasing glucose level
A. Hypoglycemia can occur with beta blocker overdoses, so an increasing blood glucose level would indicate that treatment is effective.
B. Beta blocker overdose blocks the beta receptors of the heart, which results in hypotension. The goal of treatment for a beta blocker overdose is to increase blood pressure.
C. Bradycardia can occur with beta blocker overdosage so the nurse would look for an increase in the patient’s heart rate to see if the treatment is effective.
D. Altered mental status can occur, so a treatment goal is to increase the patient’s level of consciousness.
Category: Mental Health Emergencies, Intentional overdose and ingestions
Question 86
Which of the following symptoms exhibited by a patient with recent cocaine ingestion would cause the nurse the greatest concern?
Abdominal pain
Auditory hallucinations
Poor appetite
Fever
✓
Correct Answer
Fever
A. Auditory hallucinations may result from cocaine use.
B. A patient who presents with fever and reporting recent cocaine use is at increased risk of complications. Although cocaine effects may present as hyperthermia, other complications may also present with elevations in temperature, such as aspiration or wound infections.
C. Chronic use of cocaine can result in poor appetite and malnourishment.
D. Patients may report abdominal pain with cocaine use.
Category: Medical Emergencies, Substance use and abuse (e.g., alcohol and drug
Question 87
A patient presents to triage with a laceration to the middle phalanx of the palmar side of the index finger from a kitchen knife. Bleeding has been controlled. After examining the patient for possible tendon injury, the nurse anticipates preparing the patient for wound closure by first:
administering an opioid analgesic.
cleansing and irrigating the wound.
✓
assisting with infiltration with lidocaine and epinephrine.
administering intravenous antibiotics.
Correct Answer
cleansing and irrigating the wound.
A. Remove visible contamination and dried blood by using a 4 × 4 sponge and cleansing agent. Irrigation may also be done for deep wounds. Request the physician or advanced practice provider to administer local anesthesia prior to cleaning if needed.
B. Prophylactic use of antibiotics is controversial unless the wound is considered a high risk for contamination.
C. Lidocaine 0.5–2.0% is often used because of its rapid onset (1–2 minutes) of action. Epinephrine, however, is contraindicated for distal areas (e.g., fingers, toes, nose, and earlobes) because of its vasoconstrictive effects.
D. Use of opioid analgesia is not indicated for pain associated with minor lacerations.
Category: Musculoskeletal and Wound Emergencies, Wound, Lacerations
Question 88
The nurse assesses a patient with the following signs and symptoms: increasing difficulty speaking, muffled voice, drooling, unilateral swelling to one side of the face, and tongue protruding slightly past the lips. The patient indicates that they were recently assaulted. The nurse anticipates that this patient has which of the following?
Pharyngitis
Peritonsillar abscess
Le Fort III fracture
Ludwig’s angina
✓
Correct Answer
Ludwig’s angina
A. Pharyngitis is the inflammation of the pharynx, often occurring in conjunction with the common cold. The patient will experience a reddened throat, swollen tonsils, and the presence of exudate on the tonsils.
B. Peritonsillar abscess is a purulent collection around the tonsils that can develop into a deeper tissue infection. It is often associated with a recent episode of pharyngitis or tonsillitis. If left untreated, the abscess can cause airway compromise.
C. Ludwig’s angina is a potentially fatal cellulitis that involves the floor of the mouth and the neck. The patient may have a history of a recent dental abscess that is unresponsive to therapy, or they may have experienced recent dental trauma. Signs and symptoms include swelling of the submandibular and sublingual spaces, dysphagia, drooling, and a muffled voice.
D. Le Fort III fracture is referred to as complete craniofacial disjunction and occurs as a result of significant blunt-force trauma to the face. It results in separation of the facial bones and cranial attachments. Symptoms would include bilateral periorbital ecchymosis (raccoon eyes), periorbital ecchymosis, and flattening of the facial features.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Maxillofacial
Question 89
A patient presents with a history of blunt-force trauma to the face. The patient relates falling down and striking their face on the floor. There is periorbital bruising and edema around the left eye, and the patient is complaining of diplopia. Which of the following assessment findings would confirm a diagnosis of an orbital rim fracture with entrapment of extraocular muscles?
Teardrop shape of the left pupil
Decreased ability to look upward
✓
Presence of blood in the anterior chamber
Complaint of halos around lights
Correct Answer
Decreased ability to look upward
A. The decreased ability to look upward is the result of entrapment of extraocular muscles within an orbital fracture site.
B. The presence of a teardrop-shaped pupil is a definitive sign of a ruptured globe. Patients with a ruptured globe will have a shallow-appearing anterior chamber, diminished or absent vision in the affected eye, severe ocular pain, and leakage of vitreous humor from the eye.
C. Blood in the anterior chamber of the eye is a definitive sign for the presence of hyphema.
D. The complaint or presence of halos seen around lights is characteristic of the presence of glaucoma.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Maxillofacial trauma
Question 90
A patient arrives with a large sliver of wood noted to be impaled in their right eye. Following completion of the visual acuity (Snellen) exam, what is the next intervention that the nurse should perform for this patient?
Irrigate the eye as soon as possible
Instill a topical ophthalmic anesthetic
Place a rigid eye shield over the affected orbit
✓
Apply a cotton patch to the unaffected eye
Correct Answer
Place a rigid eye shield over the affected orbit
A. There is no indication that this patient has any pain. Nothing should be put in the eye that might increase the pressure.
B. Irrigation with any type of fluid would cause a wood splinter to swell. No pressure or any form of manipulation should be applied to the eye or the wooden splinter.
C. Applying a patch to the unaffected eye will act to limit concomitant movement of the unaffected eye. The object in the affected eye will have to be secured, or a rigid eye patch applied to limit movement.
D. It is important to immobilize the penetrating object to avoid increasing the extent of damage and to prevent further disruption of the orbit. The unaffected eye should also be patched to minimize consensual movement of the affected eye.
Category: Maxillofacial and Ocular Emergencies, Ocular, Foreign bodies
Question 91
A patient presents with the complaint of a foreign body sensation and excessive pain to their left eye but denies any recent change to their vision. The patient states they were treated earlier in the week for conjunctivitis. The nurse anticipates that this patient is experiencing which of the following conditions?
Episcleritis
Subconjunctival hemorrhage
Keratitis
✓
Uveitis
Correct Answer
Keratitis
A. Uveitis or iritis is the inflammation of the uveal tract, including the iris, ciliary body, and choroid. Uveitis can be caused by inflammation, infection, or trauma. The patient frequently complains of decreased vision, photophobia, excessive tearing, and eye pain. Constriction of the pupil is usually present with uveitis.
B. Subconjunctival hemorrhage of the eye is most frequently caused by the rupture of small capillaries from trauma, coughing, sneezing, or rubbing of the eye. Although striking to look at, it is usually a benign and self-limiting condition and is not associated with vision loss, photophobia, or pain. However, patients should be instructed to avoid aspirin-containing products and nonsteroidal anti-inflammatory agents until the appearance of blood has disappeared from the conjunctiva.
C. Keratitis is the inflammation of the cornea. Symptoms may include pain, photophobia, purulent discharge, and decreased vision. Keratitis may occur secondary to preexisting or recent history of conjunctivitis and can result in corneal ulcerations, opacities, and blindness if untreated.
D. Episcleritis is an inflammatory condition affecting the episclera, located between the conjunctiva and the sclera. Episcleritis usually does not affect vision, is self-limiting, and is generally painless. Episcleritis can be associated with localized engorged vessels and nodular changes.
Category: Maxillofacial and Ocular Emergencies, Ocular, Ocular infections (e.g.,
Question 92
A patient arrives complaining of sudden onset of severe jaw pain that radiates to their ear. The patient states that they are having difficulty speaking because of the excessive pain. The pain started as they were biting into a large sandwich. The nurse anticipates that this patient has which of the following?
Angina
Periapical abscess
Temporomandibular joint syndrome
✓
Trigeminal neuralgia
Correct Answer
Temporomandibular joint syndrome
A. The pain from myocardial ischemia can often be referred to the neck and jaw, but it is not typical for this anginal pain to radiate to the ear. The nurse should keep an index of suspicion for angina as the cause of the patient’s jaw pain until a detailed history has been obtained.
B. Trigeminal neuralgia is usually a sharp, severe, stabbing recurrent pain that is paroxysmal and lasts from seconds to minutes. The recurrent pain is usually unilateral and occurs in one or more branches of the trigeminal nerve.
C. Pain from a periapical abscess is generally constant and throbbing in nature.
D. Temporomandibular joint (TMJ) syndrome is also referred to as myofascial pain dysfunction. It has several causes, including stress, malocclusion, dental disease, disease of the TMJ tissues, and poorly fitting dentures. Symptoms range from a mild ache to severe, sharp pain. The patient usually experiences pain with movement of the joint, particularly with chewing. The pain is often referred to the ear on the affected side.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Maxillofacial trauma
Question 93
Which patient would be least likely to require a tetanus booster shot?
The 13-year-old patient with a facial laceration
✓
The 70-year-old patient with burns on the leg
The 35-year-old pregnant female who sustained a laceration to the hand
The 24-year-old patient who stepped on a nail
Correct Answer
The 13-year-old patient with a facial laceration
A. Burns are a break in skin integrity, so the patient must have current tetanus immunization.
B. An adolescent patient does not require a tetanus booster if up to date on vaccinations. The current vaccination schedule requires children to receive a tetanus booster between 11 and 12 years of age.
C. Puncture wounds are typically deep and would require the patient to have current tetanus immunization.
D. Pregnancy is not a contraindication to receiving tetanus immunization; therefore, it is important to determine that this patient is current in her tetanus immunization.
Category: Musculoskeletal and Wound Emergencies, Wound, Wound infections
Question 94
The nurse is preparing to dress a stage 2 pressure injury on the shoulder of a patient. Which solution would be most appropriate to cleanse the wound bed with?
Ringer’s lactate solution
Povidone-iodine (Betadine)
Tap water
✓
Hydrogen peroxide
Correct Answer
Tap water
A. Ringer’s lactate solution is not an appropriate choice for wound bed cleansing. Normal saline would be a more appropriate choice.
B. Povidone-iodine is an inappropriate solution to use for wound bed cleansing because it can result in a reduction of defenses and lead to increased bacterial growth.
C. Hydrogen peroxide is inappropriate for wound bed cleansing because it can lead to the damage of healthy tissue.
D. Potable water (water that is suitable for drinking) or normal saline is appropriate for cleansing of the wound bed.
Category: Musculoskeletal and Wound Emergencies, Wound, Wound bleeding (e.g.,
Question 95
A patient presents complaining of a constant buzzing sound in their ear. On examination, a live insect is seen in the ear canal. Viscous lidocaine has been instilled in the ear canal. The nurse identifies that this treatment has been effective when the patient states which of the following?
“My hearing has improved in that ear now.”
“I don’t hear buzzing in my ear.”
✓
“I don’t have any more pain.”
“My ear feels numb.”
Correct Answer
“I don’t hear buzzing in my ear.”
A. The instillation of viscous lidocaine is to immobilize the insect, not numb the ear canal.
B. Live insects in the ear canal should be immobilized before removal is attempted. The administration of viscous lidocaine will immobilize the insect and stop the buzzing sound the patient has been experiencing. Mineral oil, microscope oil, and viscous lidocaine have all been used successfully for this purpose.
C. The instillation of viscous lidocaine is to immobilize the insect to decrease the likelihood of fragmentation during removal.
D. The placement of viscous lidocaine will decrease sound conduction and should not improve the patient’s ability to hear.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Maxillofacial trauma
Question 96
Acute painful episodes of gout are treated with which of the following medications?
Urate-lowering
Topical antibiotic creams
Nonsteroidal anti-inflammatory
✓
Nitrogen-containing bisphosphonates
Correct Answer
Nonsteroidal anti-inflammatory
A. Allopurinol is a urate-lowering medication that impairs conversion of xanthine to uric acid, thus inhibiting urate synthesis. This medication is more likely used for chronic gout, not as initial treatment during an acute episodic flare-up of gout.
B. Gout is a disorder of purine metabolism characterized by monosodium urate crystal deposits in specific periarticular and subcutaneous tissues that lead to acute attacks of inflammatory arthritis. Antibiotics, topical or oral, are not helpful in the treatment of gout.
C. Although indomethacin (Indocin) often is preferred, almost any nonsteroidal anti-inflammatory medication is effective in treating acute gout if prescribed in anti-inflammatory doses. Colchicine, a traditional therapy for gout, can be dramatically effective if initiated shortly after onset of acute symptoms.
D. Bisphosphonates are antiresorptive agents used to slow bone resorption and maintain bone mineral density. They help to prevent fractures and bone loss but are not indicated in the treatment of gout.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory
Question 97
A patient presents by emergency medical services (EMS) in complete cervical spine immobilization. The patient is intoxicated, and EMS reports that the patient had been drinking and jumped off the second floor of a parking garage, landing on their heels. The patient is found to have bilateral calcaneal fractures. The nurse also anticipates the patient may have experienced which of the following injuries?
Burst fracture of lumbar vertebrae 1
✓
Bilateral bipartite patella
Spinous process fracture of thoracic vertebrae 6
Spiral fracture of the femur
Correct Answer
Burst fracture of lumbar vertebrae 1
A. Spinous process fractures are more commonly associated with direct blows to the back, motor vehicle collisions, falls, and sudden twisting motions.
B. There may be other fractures associated with axial loading injuries, but the mechanism of the calcaneal fracture would not result in a spiral fracture of the femur.
C. Bipartite patella is a type of congenital abnormality of the patella and is not associated with trauma.
D. Calcaneal fractures, especially in injuries that involve the patient landing on their feet, are a type of axial loading injury where other injuries must be considered. Injuries associated with calcaneal fractures include burst fracture of the spine, tibial plateau fracture, and internal organ injuries.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament
Question 98
The nurse is discharging a patient who developed back pain 1 week ago after bending over to pick up a young child. The nurse determines that patient teaching has been effective when the patient states which of the following?
“It is important that I stop smoking so that I will heal faster.”
✓
“Nonsteroidal anti-inflammatory drugs and acetaminophen (Tylenol) are not effective pain medications.”
“I should only use ice and heat during the first 24 hours of my back pain.”
“I need to limit my activity and rest my back as much as possible.”
Correct Answer
“It is important that I stop smoking so that I will heal faster.”
A. Anti-inflammatories and acetaminophen are good options for pain relief and are very effective pain relievers.
B. It is important, and can actually help back pain, to stay active with activities that don’t strain the back, such as walking. The emergency nurse should teach proper body mechanics, especially when it comes to lifting, and instruct the patient to avoid movements that may cause strain to the back.
C. Smoking is a risk factor and associated with delayed healing for low back pain. Encouraging smoking cessation is very important for most health conditions and can assist with healing for low back pain.
D. Ice and heat are good options for back pain relief and should not be limited to the first day.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory
Question 99
Which presentation is the least likely risk for the development of compartment syndrome?
Circumferential full-thickness burn to the calf
Venomous snake bite to the forearm
Nondisplaced fracture to the medial malleolus
✓
Crush injury to the shaft of the femur
Correct Answer
Nondisplaced fracture to the medial malleolus
A. Snake bites are soft-tissue injuries that can lead to significant edema in the compartment, placing the patient at risk for developing compartment syndrome.
B. Crush injuries tend to be associated with compartment syndrome because they cause significant swelling of the soft tissues, which can increase the compartmental pressure. In addition, pressure from an external force, such as when a heavy object falls on a patient, can increase the risk of developing compartment syndrome.
C. Circumferential burn injuries are associated with increased risk for compartment syndrome. Soft-tissue injuries and burns are associated with edema, which causes an increase in compartmental pressure. This type of injury may require a fasciotomy or escharotomy to relieve the compartment pressure.
D. Most malleolus fractures are associated with inversion or eversion injuries related to ankle sprains. This fracture is nondisplaced, and the patient most likely will need only to be splinted or have a cast applied to the ankle area. Although there is swelling associated with this injury, it is not within a compartment; therefore, the risk for compartment syndrome is generally low.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Compartment
Question 100
The nurse is assessing a patient with a history of sickle cell disease (SCD) who is experiencing wheezing, fever, and shortness of breath. Which high-morbidity complication of SCD does the nurse suspect this patient is experiencing?
Acute chest syndrome
✓
Splenic sequestration
Priapism
Pulmonary hypertension
Correct Answer
Acute chest syndrome
A. Priapism is a painful erection and a genitourinary emergency in which red blood cells sickle and become lodged in the microvasculature, leading to entrapment of blood in the penis. Symptoms do not typically include fever, wheezing, or dyspnea.
B. Acute chest syndrome occurs when sickle-shaped red blood cells attach to the lung endothelium that is already inflamed, and the failure of the lung tissue to be reoxygenated leads to additional inflammation and lung infarction. Approximately 25% of all deaths in people with SCD are due to acute chest syndrome. Symptoms include chest pain, dyspnea, fever, cough, wheezing, hypoxemia, and pulmonary infiltrates.
C. Pulmonary hypertension is a chronic complication with SCD. Approximately 10% of SCD patients will develop pulmonary hypertension, and it is associated with an increased mortality rate. Symptoms include dyspnea, fatigue, and chest pain.
D. Patients with SCD are at high risk for splenic issues, and this complication occurs primarily in children. Splenic sequestration occurs when large amounts of blood become pooled in the spleen; because the spleen can hold one-fifth of the body’s blood supply, high mortality rates are associated with splenic sequestration resulting in cardiovascular collapse. Symptoms would be abdominal pain and signs of hypovolemic shock, weakness, pallor, tachycardia, and hypotension.
Category: Medical Emergencies, Hematologic disorders
Question 101
A patient with a long-term history of dexamethasone (Prednisone) use for urticaria presents with a swollen abdomen with pink stretch marks and elevated blood pressure. The patient’s arms and legs are very thin, their face is round, their skin is very thin, and there is a buffalo hump between their shoulders. Which of the following conditions aligns with the patient’s symptoms?
Syndrome of inappropriate antidiuretic hormone
Cushing’s syndrome
✓
Hashimoto disease
Thyrotoxicosis
Correct Answer
Cushing’s syndrome
A. Hashimoto disease is a condition in which the immune system attacks the thyroid gland, causing the gland to malfunction, and leading to a decrease in the secretion of thyroid hormones. Symptoms include fatigue, hair loss, puffy face, and increased sensitivity to cold.
B. Thyrotoxicosis is the result of severe thyroid dysfunction, causing hyperthyroidism. Hyperdynamic vital signs along with central nervous system dysfunctions are common signs.
C. Syndrome of inappropriate antidiuretic hormone is caused by abnormal amounts of antidiuretic hormone being released from the pituitary gland, resulting in water intoxication. This condition can be a result of head injury, infections, or certain drugs (antihypoglycemic agents, psychotropic drugs, and antineoplastic drugs). Symptoms include headache, fatigue, confusion, seizures, and weight gain.
D. Cushing’s syndrome is a collection of symptoms that can be attributed to prolonged exposure to cortisone. Classic signs and symptoms include a swelling fat pad at the base of the neck and upper spine, known as a buffalo hump; hypertension; abdominal swelling; thin extremities; striations along the abdomen; and a round moon face. A tumor of the adrenal gland can also cause Cushing’s syndrome.
Category: Medical Emergencies, Endocrine disorders
Question 102
Which of the following conditions is a rare, life-threatening, and serious complication of hypothyroidism?
Thyroid storm
Myxedema coma
✓
Adrenal crisis
Cushing’s syndrome
Correct Answer
Myxedema coma
A. Adrenal crisis, also known as acute adrenal insufficiency, is a life-threatening condition caused by a decrease in cortisol and aldosterone levels. This results in sodium and water loss from both the kidneys and gastrointestinal tract, causing the patient to become hypotensive and hypovolemic. As the body loses sodium, there is an increase in potassium, leading to hyperkalemia and the development of fatal dysrhythmias. Treatment includes fluid replacement, correction of hyperkalemia, and hydrocortisone administration.
B. Myxedema coma is a rare, life-threatening, and serious complication of hypothyroidism that affects older patients with pulmonary or vascular disease. Patients complain of fatigue, shortness of breath, and weight gain, and may experience tongue swelling. Treatment includes support of the patient’s airway, breathing, and circulation (ABCs), as well as thyroid hormone replacement.
C. Thyroid storm, also known as thyrotoxic crisis, is a rare, life-threatening, and serious complication of hyperthyroidism. Patients present with agitation, tachydysrhythmias, tachypnea, and fever. Treatment includes support of the patient’s airway, breathing, and circulation (ABCs), fever control, propylthiouracil, and iodine.
D. Cushing’s syndrome is the result of prolonged exposure to glucocorticoids (either endogenous or exogenous) that causes the patient to develop a Cushingoid appearance, characterized by an increased amount of adipose tissue to the face, upper back, and base of the neck.
Category: Medical Emergencies, Endocrine disorders
Question 103
During ongoing assessment of a patient with pelvic fracture, the nurse is no longer able to palpate distal pulses, and the patient has an altered mental status. Which of the following conditions could be responsible for this change in the patient’s status?
Hemorrhage
✓
Neurogenic shock
Fat embolism
Compartment syndrome
Correct Answer
Hemorrhage
A. Most instances of fat embolism are asymptomatic, but in symptomatic patients, there is a classic triad presentation of (1) decreased mental status that starts with restlessness and agitation; (2) respiratory distress, including dyspnea and hypoxia; and (3) petechial rash on the head, neck, anterior thorax, conjunctivae, buccal mucous membranes, and axillae. Fat emboli occur in patients with multiple fractures or as a complication after orthopedic surgery.
B. Signs and symptoms of decompensated or progressive shock include an altered level of consciousness; the presence of weak, thready, or absent pulses; and cool, clammy, cyanotic skin as the blood shunts to vital organs.
C. The six Ps associated with assessment of compartment syndrome are pain, pressure, pallor, pulses, paresthesia, and paralysis. Compartment syndrome does not directly result in an altered mental status change.
D. Neurogenic shock is a type of distributive shock that occurs as a result of maldistribution of an adequate circulating blood volume. It usually occurs with spinal cord injury, resulting in the loss of sympathetic nervous system control of vascular tone, which produces venous and arterial vasodilation.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures
Question 104
Which of the following laboratory trends does the nurse expect to be present in a patient diagnosed with disseminated intravascular coagulation?
Increased platelet count, decreased D-dimer, and prolonged prothrombin
Increased platelet count, elevated D-dimer, and prolonged prothrombin time
Decreased platelet count, increased fibrinogen, and decreased D-dimer
Decreased platelet count, elevated d-dimer, and prolonged prothrombin time
✓
Correct Answer
Decreased platelet count, elevated d-dimer, and prolonged prothrombin time
A. Disseminated intravascular coagulation results in a depletion of clotting factors due to diffuse microvascular clot formation. These clots are triggered by hemorrhage and dilution, often related to resuscitation after hemorrhage or the presence of a specific disease state such as sepsis, liver disease, or cancer. Platelets will decrease because of the rapid loss of blood. The d-dimer is a product of fibrin degradation.
B. The D-dimer will be elevated and the prothrombin time prolonged, but the platelet count will decrease because of the rapid loss of blood.
C. The platelet count will decrease along with fibrinogen. Platelets will decrease because of the rapid loss of blood. Fibrinogen is rapidly depleted because of the reduction of clotting factors and formation of clots.
D. The platelet count will be decreased, and the D-dimer will be elevated. The prothrombin time will be prolonged because the clotting cascade has been disrupted, causing an interference with the blood’s ability to clot.
Category: Medical Emergencies, Hematologic disorders
Question 105
A patient diagnosed with septic shock remains hypotensive after receiving fluid resuscitation with an isotonic crystalloid solution. Which of the following priority interventions would be initiated to assist in maintaining the patient’s mean arterial blood pressure at 65 mm Hg or higher?
Infusion of vasopressors
✓
Transfuse packed red blood cells
Transfuse hydroxyethyl starches
Add albumin to the current crystalloid solution
Correct Answer
Infusion of vasopressors
A. The use of hydroxyethyl starches, such as Hespan or Boluven, is not recommended to correct hypotension in septic shock; in some studies, it has been found to increase the risk of renal failure.
B. Currently, the use of albumin is not recommended as a treatment for hypotension during the resuscitation phase of the patient in septic shock.
C. Blood transfusions are not recommended in the management of hypotension in the presence of septic shock unless the patient’s hemoglobin is 7 g/dL or lower.
D. The severe sepsis bundles recommend that if resuscitation with crystalloid does not correct the patient’s hypotension, a vasopressor such as norepinephrine, epinephrine, or phenylephrine should be initiated to maintain a mean arterial pressure of 65 mm Hg or higher.
Category: Medical Emergencies, Sepsis
Question 106
A patient with a history of Addison’s disease complains of nausea, weakness, fatigue, and anorexia. The patient has an order for hydrocortisone. Which of the following therapeutic outcomes would the nurse anticipate after administration of this medication?
Increase in patient weight
Decrease in serum glucose
Increase in blood pressure
✓
Decrease in serum sodium
Correct Answer
Increase in blood pressure
A. This patient is displaying symptoms of acute adrenal crisis, which can occur after abrupt cessation of methylprednisolone (Prednisone). Signs and symptoms include hypotension; tachycardia; fatigue; nausea; hyperpigmentation of the knuckles; creases in the hands, axilla, and gums; and electrolyte abnormalities: hyponatremia, hypoglycemia, hyperkalemia, and hypercalcemia. Hemodynamic stability is a high priority and is a therapeutic outcome the nurse should expect after administration of hydrocortisone.
B. Patients who present in adrenal crisis may present with hyponatremia as a result of lack of the glucocorticoid cortisol and the mineralocorticoid aldosterone. A therapeutic outcome of administration of hydrocortisone and dexamethasone is increased sodium.
C. Patients who present in adrenal crisis may present with hypoglycemia as a result of lack of the glucocorticoid cortisol. A therapeutic outcome of administration of hydrocortisone is increased glucose.
D. Patients who present in adrenal crisis will likely have recent weight loss; however, weight gain may not occur immediately with treatment. Correction of hemodynamic instability is a higher-priority expected outcome.
Category: Medical Emergencies, Endocrine disorders
Question 107
A patient has been diagnosed with thrombocytopenia. The nurse is aware that which laboratory value has confirmed this diagnosis?
Platelet count of 5000 μL
✓
Platelet count of 900,000 μL
White blood cell count of 8000 μL
White blood cell count of 26,000 μL
Correct Answer
Platelet count of 5000 μL
A. A white blood cell count of 8000 μL is a normal value and would not define thrombocytopenia or a low platelet count.
B. Thrombocytopenia is defined as a very low platelet count. The platelet count normally ranges from 150,000 to 400,000 μL. A level of 5000 μL would be very low, and the patient may display bleeding tendencies. Thrombocytopenia has various causes, including failure of the bone marrow to produce platelets, and platelets being destroyed or broken down in the bloodstream, spleen, or liver.
C. This value of 900,000 μL is a markedly elevated platelet count is referred to as thrombocytosis. A normal platelet count is 150,000 to 400,000 μL.
D. A white blood cell (WBC) count of 26,000 μL is defined as leukocytosis and would indicate that an infectious process is present in the patient. A normal WBC count is 3600 to 10,400 μL.
Category: Medical Emergencies, Hematologic disorders
Question 108
Which laboratory test result would indicate that a patient’s psychotic symptoms may be related to a medical condition and not a psychiatric condition?
A calcium level of 6.9 mg/dL
A magnesium level of 1.0 mg/dL
A blood glucose level of 30 mg/dL
✓
A potassium level of 3.0 mEq/L
Correct Answer
A blood glucose level of 30 mg/dL
A. A normal magnesium level is 1.5–2.5 mEq/L. Hypomagnesemia signs and symptoms include nausea, vomiting, increased deep tendon reflexes, and muscle weakness.
B. A normal potassium level is 3.5–5.0 mEq/L. Hypokalemia signs and symptoms include muscle weakness, paresthesia, and cardiac dysrhythmias.
C. A normal serum glucose level is 80–100 mg/dL. Any level below 70 mg/dL is considered hypoglycemic. Symptoms of severe hypoglycemia include pale skin, diaphoresis, and an altered mental status, which may cause the patient to experience severe confusion, abnormal mentation, and hallucinations.
D. A normal calcium level is around 8–10 mg/dL. Hypocalcemia signs and symptoms include muscle twitching/cramping, numbness and tingling of extremities, constipation, and cardiac dysrhythmias.
Category: Mental Health Emergencies, Thought disorders (e.g., psychosis,
Question 109
Which of the following statements made by a patient being treated for diabetic ketoacidosis would indicate that an untoward effect was occurring during the treatment phase?
“Can I have something for this back pain that has been getting worse?”
“I have developed a pretty serious headache in the past hour.”
✓
“I feel like I am aching all over.”
“I feel like I need to urinate very badly.”
Correct Answer
“I have developed a pretty serious headache in the past hour.”
A. A too-rapid decrease in blood glucose level can cause the development of cerebral edema, which could be indicated by the headache. The emergency nurse should be on alert for any manifestations of increased intracranial pressure, such as dizziness, visual disturbances, nausea, vomiting, change in speech patterns, or decrease in level of consciousness.
B. The urgency to urinate may be related to the patient having received several liters of fluid and is not an indicator of an untoward effect of the treatment.
C. The patient may have had to stay in bed for an extended period or may have chronic back pain issues, but back pain is not a side effect of the treatment for diabetic ketoacidosis.
D. Aching all over is a complaint that will be discussed with the provider, but it does not indicate a major concern related to the treatment regimen.
Category: Medical Emergencies, Endocrine disorders
Question 110
A female patient who has sustained a 4-inch laceration to the left anterior thigh arrives via an ambulance. She is anxious and continually states, “I am a bleeder! I know I will need some factor VIII! Get it quick!” The nurse is aware that this patient is likely referring to which coagulopathy?
Hemophilia A
Hemophilia B
Von Willebrand disease
✓
Christmas disease
Correct Answer
Von Willebrand disease
A. Hemophilia B is a sex-linked inherited disorder that results in factor IX deficiency or functionality. The hemophilia B gene is carried by the female, who passes it on to her children; however, the disease almost always manifests in males.
B. Hemophilia A is a sex-linked inherited disorder that results in factor VIII deficiency or functionality. The hemophilia A gene is carried by the female, who passes it on to her children; however, the disease is almost always found in males.
C. Von Willebrand disease is a genetically inherited bleeding disorder. The disease is manifested in both male and female patients. It is caused by defects in the adherence of platelets, a low level of factor VIII, and decreased levels of von Willebrand factor.
D. Christmas disease is another name for hemophilia B, which is a lack of, or a decrease in the functionality of, factor IX. This disease is primarily seen in male patients.
Category: Medical Emergencies, Hematologic disorders
Question 111
The new patient placed in the treatment room for evaluation is presently calm, cooperative, and following directions. The patient was brought in by law enforcement for attempting to kill their brother with a knife. Which of the following interventions would be the highest priority for the nurse during initial assessment?
Approach the patient early with a display of a power attitude
Instruct the patient to undress completely
✓
Offer the patient food or drink as soon as possible
Place the patient in soft restraints
Correct Answer
Instruct the patient to undress completely
A. It is appropriate to offer psychiatric patients food or drink at some point, but this should not be the primary concern at the time of the initial assessment. The safety of everyone in the emergency department should be the emergency nurse’s primary concern.
B. It may be necessary to display a sense of power to the patient, either in demeanor or with a show of power through the presence of multiple security officers or other staff members in attendance. However, this approach should only be used if it becomes absolutely necessary because of the patient’s aggressive or uncooperative behavior. The highest priority is to get the patient completely undressed and all clothing searched for possible weapons.
C. It is most important that all patients who are exhibiting psychiatric emergencies be undressed completely. The patient’s clothes, including pockets, should be checked for any items that could be used to harm oneself or others. Items such as guns and knives can be hidden under or inside clothing. A safe environment is one in which patients do not have access to anything that could harm themselves or others.
D. This patient is calm and cooperative, so the application of restraints is not indicated at this time.
Category: Mental Health Emergencies, Homicidal and suicidal ideation
Question 112
The nurse has provided discharge education to the parents of a child who experienced a febrile seizure. Which of the following statements by the parent indicates to the nurse that the teaching has been effective?
“Febrile seizures occur most often in children over the age of 2.”
“Checking the temperature under the arm is preferred because it is the easiest.”
“Aspirin and acetaminophen are the preferred medications for reducing a fever.”
“Febrile seizures most often occur because of a rapid rise in the body’s temperature.”
✓
Correct Answer
“Febrile seizures most often occur because of a rapid rise in the body’s temperature.”
A. In children, a rectal temperature measurement is considered the most accurate and preferred method, especially in the very young. An axillary temperature reading is often 1–2°F lower than a rectal temperature.
B. Acetaminophen and ibuprofen are acceptable medications for fever reduction. Aspirin-containing products should be avoided in children with acute febrile illnesses because of the association with the development of Reye’s syndrome.
C. The peak incidence of febrile seizures occurs in children under the age of 2, but the range is from 5 months to 5 years.
D. A rapid rise in the body’s temperature, not the actual degree of the temperature, is often the cause of febrile seizures. The rapid rise irritates the immature nervous system and often causes the seizure activity.
Category: Medical Emergencies, Sepsis
Question 113
Your patient has developed signs of neuroleptic malignant syndrome, including agitated delirium, confusion, and hyperthermia. Which of the following interventions would have the highest priority for the nurse to perform?
Application of a cooling blanket
Insertion of a urinary catheter
Administration of a dopamine agonist
Discontinue the precipitating agent
✓
Correct Answer
Discontinue the precipitating agent
A. Application of a cooling blanket is an important intervention for treating the presence of hyperthermia in patients with neuroleptic malignant syndrome, but it is not the first treatment.
B. Neuroleptic malignant syndrome is associated with the use of antipsychotic medications. Removing the offending agent(s) is the first and most important intervention in treatment. Patients with neuroleptic malignant syndrome will exhibit fever, muscle rigidity, an altered level of consciousness, and dysfunction of the autonomic nervous system.
C. Administration of a dopamine agonist is an optional intervention for treating neuroleptic malignant syndrome, but it is not the first treatment.
D. Insertion of a urinary drainage catheter is an important intervention for assessing for complications of neuroleptic malignant syndrome, but it is not the first intervention to be performed.
Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 114
Which of the following assessment findings would the nurse be most concerned about in a hemophiliac patient with hemarthrosis?
Skin breakdown
Paresthesia
✓
Severe pain
Impaired range of motion
Correct Answer
Paresthesia
A. Skin breakdown is a potential finding with hemarthrosis but is not threatening to life or limb.
B. Severe pain is often noted in patients with hemarthrosis, but it is not limb or life threatening. Pain that is disproportionate to the injury can be associated with compartment syndrome and requires further evaluation.
C. If bleeding extends into the surrounding tissues, paresthesia can be an indicator of the presence of compartment syndrome. The collection of blood and edema can compress nerves and vasculature, reducing distal circulation and leading to tissue damage; it can be both limb and life threatening.
D. Impaired range of motion is often noted in patients with hemarthrosis but is not threatening to life or limb.
Category: Medical Emergencies, Hematologic disorders
Question 115
A patient currently receiving high-dose chemotherapy for treatment of non-Hodgkin’s lymphoma presents with a minor hand laceration. Which of the following treatment areas would be most appropriate for this patient?
Back in the waiting room
A quick care or rapid care minor treatment area
A room with protective isolation precautions
✓
Any available room
Correct Answer
A room with protective isolation precautions
A. The patient should be removed from the waiting room with other potentially infectious patients or visitors.
B. The high-dose chemotherapy used to treat Hodgkin’s disease and non-Hodgkin’s lymphoma results in profound neutropenia and incurs significant risk in terms of mortality and morbidity as a result of infection. Protection from infection is of vital importance, and patients should receive care in an isolation environment.
C. The patient should receive treatment in a room that limits their exposure to other patients and involves the fewest staff members possible.
D. A minor treatment area places the patient at risk for contracting an infectious process.
Category: Medical Emergencies, Immunocompromise (e.g., HIV/AIDS,
Question 116
A patient recently diagnosed with hypertension presents with severe swelling around their eyes and lips. Which of the following medications most likely caused the patient’s symptoms?
Lisinopril (Zestril)
✓
Midodrine (ProAmatine)
Diltiazem (Cardizem)
Losartan (Cozaar)
Correct Answer
Lisinopril (Zestril)
A. Midodrine is indicated in the treatment of orthostatic hypotension. It is an alpha-specific adrenergic agonist whose administration leads to vasoconstriction, thereby increasing the patient’s vasculature tone and blood pressure. Midodrine is not indicated in the treatment of hypertension.
B. Losartan is an angiotensin II receptor blocker (ARB). ARBs are used to treat hypertension, but they are not associated with the development of angioedema as an allergic reaction to the medication. Side effects of an ARB include headache, dizziness, syncope, and weakness.
C. Diltiazem is a calcium channel blocker (CCB). CCBs are not associated with the development of angioedema as an allergic reaction to the medication. Potential side effects of a CCB include dizziness, lightheadedness, headache, and fatigue. The patient is not complaining of these medication side effects.
D. The patient is experiencing signs of angioedema, a side effect of angiotensin-converting enzyme inhibitor (ACE-I) drugs. ACE-I-induced angioedema is occurring with increasing frequency because of the popularity of these medications in treating hypertension and heart failure. The incidence of angioedema is approximately 5 times greater in patients of African American descent than in patients in other ethnic groups.
Category: Medical Emergencies, Allergic reactions and anaphylaxis
Question 117
A patient with a recent diagnosis of terminal cancer verbalizes a desire to commit suicide, stating, “I will just get my shotgun when things get bad” and “You can’t stop me from driving my pickup into a tree.” What is the priority intervention the nurse should implement for the patient and family?
Explain to the family that the patient is experiencing a normal reaction to the news of the diagnosis
Reassure the patient that they will be provided with resources such as hospice care
Call security to assist with a safety check of the patient and their room
✓
Arrange for follow-up with a mental health provider for antidepressants
Correct Answer
Call security to assist with a safety check of the patient and their room
A. The thoughts the patient is having may be a part of the grief process following news of a terminal illness, but securing the patient’s safety is the highest priority.
B. The patient is too distraught to learn about end-of-life care at this time. The highest priority is to ensure their safety.
C. The patient is in crisis and needs immediate attention in the emergency department. Once medically cleared, the patient will be evaluated by a mental health provider.
D. The patient is verbally expressing suicidal ideation with a plan. Securing the safety of the patient and staff is the highest priority. Security personnel can help facilitate a safety check to ensure the patient does not have anything they can use to harm themselves or others, and assist with transport to a safe area.
Category: Mental Health Emergencies, Homicidal and suicidal ideation
Question 118
A patient presents with trouble sleeping because of nightmares, fear when driving or riding in cars, and frequent thoughts of the incident related to a severe motor vehicle collision they were involved in 2 months ago. The patient has been treated six times for a variety of complaints since the incident. What behavioral health disorder should the nurse consider when assessing this patient?
Depression
Agoraphobia
Bipolar disorder
Posttraumatic stress disorder (PTSD)
✓
Correct Answer
Posttraumatic stress disorder (PTSD)
A. Agoraphobia (perception of an unsafe environment, feelings of being trapped, helpless, or embarrassed) may occur with PTSD and other anxiety disorders, but the patient is not reporting these symptoms.
B. Although stressful life events can contribute to the onset of depression, symptoms typically include depressed mood, anhedonia, difficulty concentrating, insomnia or hypersomnia, weight changes, and thoughts of suicide.
C. Symptoms of bipolar disorder include periods of depression cycling with periods of mania (including elevated, expansive, or irritable mood).
D. Patients who return often to the emergency department following a serious trauma should be questioned regarding ongoing pain, coping skills, and general well-being. Symptoms of PTSD include fear, intrusive recollections, dreams of the event, and avoidance of stimuli associated with the trauma. Early recognition of symptoms may facilitate early treatment and increase the incidence of a successful recovery.
Category: Mental Health Emergencies, Anxiety disorders (e.g., PTSD, anxiety, panic
Question 119
A patient from the clinic presents with increasing agitation and verbal and physical abuse of a staff member after being denied narcotics. Which of the following initial interventions would be the priority for this patient?
Intramuscular administration of an anxiolytic
De-escalation with verbal instructions
✓
Placement of the patient in seclusion
Placement of four-point restraints
Correct Answer
De-escalation with verbal instructions
A. Physical restraints are not the first-line treatment intervention for an agitated patient.
B. Agitated, violent, and aggressive patients pose a threat to nurses and are at risk of harming themselves or those around them. Nonpharmacologic interventions, such as verbal intervention, to de-escalate an agitated, psychotic patient should be attempted first, and an optimal response would be the patient following verbal instruction.
C. Intramuscular injection of an anxiolytic medication may be indicated for a patient who is not able to follow verbal instruction and respond with controlled behavior.
D. Although seclusion with constant observation is a part of the treatment regimen for an agitated patient, verbal de-escalation should be attempted initially and involve providing clear instructions to the patient.
Category: Mental Health Emergencies, Aggressive and violent behavior
Question 120
During the assessment of a 6-month-old child, the nurse identifies the presence of a possible spiral leg fracture. The parents state that the child rolled off a bed onto the floor. Based on this assessment, the nurse prepares for which of the following?
Report suspicion of child maltreatment to the child protective services agency
✓
Record all verbal interactions between the parents and emergency providers
Do not permit the parents to hold the child
Separate the parents and ask each what event led to the child’s leg injury
Correct Answer
Report suspicion of child maltreatment to the child protective services agency
A. This is not the responsibility of the providers. Based on assessment and evaluation by child protective services surrounding the events leading to the child’s injury, law enforcement will be responsible for determining the exact order of events.
B. There is no indication that the parents should not be allowed to hold or comfort their child. It is unknown if either parent is responsible for the injury, or under what circumstances the injury actually occurred.
C. It is important to obtain an accurate history of the events leading to the child’s injury; however, it is not necessary to record all verbal interactions between the parents and emergency personnel unless they are related to the actual events surrounding the child’s injury.
D. Healthcare providers are mandated reporters and are required by law to report cases of suspected child maltreatment to the local authorities. The presence of a spiral fracture in a nonambulatory child has been associated with the presence of physical child maltreatment and is the result of an intentional twisting motion to the extremity. The reported mechanism of injury is not consistent with a spiral fracture.
Category: Mental Health Emergencies, Aggressive and violent behavior
Question 121
A patient with myxedema coma is most likely to seek care in which season of the year?
Spring
Summer
Winter
✓
Fall
Correct Answer
Winter
A. Patients with hypothyroidism have an intolerance for cooler or cold temperatures, which is related to their decreased metabolism. Myxedema coma (hypothyroid coma) is more commonly seen in the winter months because of exposure to cold temperatures or a cold environment. More than 90% of myxedema coma cases occur during the winter months, and they are more common in women over the age of 60.
B. More than 90% of myxedema coma cases occur during the winter months.
C. More than 90% of myxedema coma cases occur during the winter months.
D. More than 90% of myxedema coma cases occur during the winter months.
Category: Medical Emergencies, Endocrine disorders
Question 122
A young child presents with signs and symptoms of diabetic ketoacidosis. Which of the following intravenous (IV) fluids does the nurse anticipate administering to correct the child’s moderate dehydration status?
10–20 mL/kg of 0.9% sodium chloride IV over 1 hour
✓
20 mL/kg of 0.9% sodium chloride rapid IV push over 15 minutes
10–20 mL/kg dextrose 5% with 0.9% sodium chloride IV over 2 hours
30 mL/kg bolus of 0.9% sodium chloride IV over 1 hour
Correct Answer
10–20 mL/kg of 0.9% sodium chloride IV over 1 hour
A. In the moderately dehydrated child, isotonic crystalloid IV fluid should be administered slowly over 1 hour to avoid cerebral edema. If the patient is hemodynamically unstable, the bolus should be given over 10–15 minutes.
B. Rapid infusions of large amounts of fluid may lead to cerebral edema.
C. Infusions of large amounts of IV fluid may lead to fluid overload and cerebral edema.
D. Dextrose should not be added to IV fluids until the child’s serum blood glucose is below 250 mg/dL. The administration of dextrose 5% with 0.9% sodium chloride will not treat the acute dehydration and may cause the child’s blood glucose to increase.
Category: Medical Emergencies, Endocrine disorders
Question 123
A patient who was recently prescribed fluoxetine (Prozac) presents tearful and trembling, and states, “I can’t take it anymore . . . this new medication the doctor gave me is not working!” What intervention by the nurse would have the most significant impact on this patient?
Instruct the patient to stop the medication immediately and follow up with the physician.
Request a benzodiazepine such as lorazepam (Ativan) to calm the patient’s nerves.
Reassure the patient that it can take 1–4 weeks before a noticeable improvement is evident.
✓
Inform the patient that the provider will likely change the medication given that symptoms are worsening.
Correct Answer
Reassure the patient that it can take 1–4 weeks before a noticeable improvement is evident.
A. Antianxiety agents (benzodiazepines) should not be administered until the patient has been evaluated by the emergency physician or advanced practice provider.
B. The nurse should never tell a patient that medication orders will be changed without someone first discussing the patient’s symptoms with their therapist or psychiatrist.
C. Fluoxetine, an SSRI, should never be stopped abruptly. Patients should be slowly weaned off the medication in conjunction with appropriate follow-up and the possibility of another medication regimen being initiated.
D. SSRIs, including fluoxetine, inhibit reuptake of serotonin and are used in treatment of major depressive disorders. It may take up to 4 weeks to reach therapeutic levels and see improvement. Frequent follow-up with the prescribing provider is required, and dosage adjustments may be needed if no improvement is evident within 4 weeks.
Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 124
When caring for a patient who has been recently diagnosed with chronic lymphocytic leukemia, the nurse should consider which assessment variation?
Sudden onset of initial symptoms is related to thrombocytosis.
Hepatomegaly and splenomegaly are common assessment findings.
✓
Early symptoms of fatigue may be related to the presence of thrombocytopenia.
Leukemia is a nonmalignant neoplasm.
Correct Answer
Hepatomegaly and splenomegaly are common assessment findings.
A. Thrombocytosis is a disorder in which the body produces too many platelets. It is not a symptom of leukemia. Thrombocytopenia, or reduced platelets, is a result of bone marrow depression and is common in patients with leukemia or those who are undergoing chemotherapy.
B. Leukemic cells may invade the liver and spleen, resulting in enlargement of both organs.
C. Leukemia is referred to as “blood cancer” and is a disease of malignant hematopoietic stem cells.
D. General malaise and fatigue are related to anemia, not thrombocytopenia. Immature white blood cells proliferate in the circulatory system and result in fewer mature red blood cells.
Category: Medical Emergencies, Hematologic disorders
Question 125
An adolescent is being evaluated for abdominal pain. When the mother leaves the exam room to make a phone call, the patient reveals to the nurse that they are being sexually fondled at school by a teacher. What is the priority nursing intervention for this patient?
Report the name of the alleged abuser to law enforcement immediately.
Obtain consent from the mother to report the abuse to the appropriate agency.
Discuss birth control and sexually transmitted infection prevention with the patient.
Notify the appropriate child protective services or law enforcement agency.
✓
Correct Answer
Notify the appropriate child protective services or law enforcement agency.
A. Sexual abuse of children is a crime in all states. As a mandated reporter, the nurse has a legal responsibility to report alleged sexual abuse to the appropriate local agency.
B. Parental consent is not required for mandated reporting of alleged sexual abuse of a minor.
C. The investigation of sexual assault is the responsibility of the local child maltreatment or law enforcement agency. If the child names the person, it should be included in the nurse’s documentation.
D. Discharge teaching after an appropriate examination would be done as part of the discharge process, but it is not the highest-priority intervention.
Category: Professional Issues, Patient, Abuse and neglect
Question 126
A patient is being discharged with a lower leg cast. The patient is concerned about how they will be able to walk up and down the steps with crutches at home. Which of the following is the correct instruction for the use of crutches on the stairs?
Going up, start with the uninjured leg, and going down, start with crutches and then the uninjured leg.
Going up, start with the injured leg, and going down, start with crutches and then the injured leg.
Going up, start with the injured leg, and going down, start with crutches and then the uninjured leg.
Going up, start with the uninjured leg, and going down, start with crutches and then the injured leg.
✓
Correct Answer
Going up, start with the uninjured leg, and going down, start with crutches and then the injured leg.
A. Going up stairs, the uninjured leg goes up on the first step, followed by the injured leg and crutches. Going down the stairs, place the crutches down one step, step down with the injured leg, and follow with the uninjured leg.
B. Going up stairs, the uninjured leg goes up on the first step, followed by the injured leg and crutches. Going down the stairs, place crutches down one step, step down with the injured leg, and follow with the uninjured leg.
C. Going up stairs, the uninjured leg goes up on the first step, followed by the injured leg and crutches. Going down the stairs, place crutches down one step, step down with the injured leg, and follow with the uninjured leg.
D. Going up stairs, the uninjured leg goes up on the first step, followed by the injured leg and crutches. Going down the stairs, place crutches down one step, step down with the injured leg, and follow with the uninjured leg.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures
Question 127
A patient sustained a compression fracture of the lumbar spine after landing on both feet following a jump from a third-story window. There was no loss of consciousness, the spine is intact, the Glasgow Coma Scale score is 15, and the patient complains of lumbar pain. What other associated injuries will the nurse assess the patient for?
Subdural hematoma
Calcaneus fracture
✓
Femur fracture
Foreign body impalement
Correct Answer
Calcaneus fracture
A. Impalement of a foreign body results from penetrating trauma. This results in an open wound from the foreign object that may or may not be present.
B. Femur fractures result from high-energy transfer. Femur fractures can occur in conjunction with knee trauma or result from a direct blow to the femur. Signs and symptoms include pain radiating to the groin, swollen thigh, and limited range of motion. Femur fractures may result in significant blood loss into the surrounding tissue.
C. Subdural hematoma occurs as a result of hemorrhage in the subdural space and may be either acute (after severe trauma) or chronic (over a period of days or weeks). Risk increases in those who use anticoagulants; alcoholics; and the elderly (cerebral atrophy).
D. Calcaneus fractures can occur in jumps or falls when the patient lands directly on their feet. The energy load of landing feet first can result in calcaneus fractures and vertebral body fractures.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures
Question 128
A patient presents with a forearm amputation with brisk arterial bleeding. A tourniquet will be applied. Which of the following is correct regarding application of a tourniquet?
The tourniquet should slow or stop bleeding but not cause a lot of pain.
Pull up the sleeve of the shirt before applying the tourniquet.
Place the tourniquet away from the wound so dressings can be applied.
If one tourniquet does not stop the bleeding, a second may be applied.
✓
Correct Answer
If one tourniquet does not stop the bleeding, a second may be applied.
A. The tourniquet should be placed as close to the wound as possible to limit the amount of ischemia and nerve compression.
B. The tourniquet should be tight enough to control arterial bleeding and will be extremely painful when applied properly. Make sure to offer pain medication.
C. The tourniquet should be placed over any clothing so as not to hide it. The tourniquet should be visible at all times and marked with the time it was applied. Any clothing will provide a small amount of padding underneath the tourniquet.
D. If a single tourniquet does not control the bleeding, a second tourniquet should be placed 2 inches above the first. You can also tighten the first tourniquet.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures
Question 129
A patient complains of decreased vision, intense headache, and the appearance of halos around lights with photophobia. The nurse identifies these symptoms as being consistent with which of the following conditions?
Central retinal artery occlusion
Corneal abrasion
Iritis
Acute angle-closure glaucoma
✓
Correct Answer
Acute angle-closure glaucoma
A. Central retinal artery occlusion is associated with the sudden loss of vision in the affected eye. It is considered an ophthalmology emergency and requires immediate intervention to prevent permanent loss of vision in the affected eye.
B. The patient’s presenting signs and symptoms are consistent with the presence of acute angle-closure glaucoma. A blockage occurs in the eye so that aqueous fluid is unable to exit, producing increasing pressure. If not identified and treated within a few hours, it can cause blindness.
C. A patient with corneal abrasion would experience photophobia with the development of excessive tearing and pain in the affected eye.
D. Iritis is associated with the development of intense unilateral pain, irritated conjunctiva, edema, and excessive tearing with photophobia.
Category: Maxillofacial and Ocular Emergencies, Ocular, Increased intraocular
Question 130
A patient with cerebral edema has received intravenous mannitol. Which of the following clinical signs would indicate that this intervention has had the desired effect?
Urinary output of 500 mL in the last hour
✓
Intracranial pressure (ICP) reading of 60 mm Hg
Cerebral perfusion pressure of 30 mm Hg
Systolic blood pressure of 80 mm Hg
Correct Answer
Urinary output of 500 mL in the last hour
A. Cerebral autoregulation can be impaired or lost following brain injury, and cerebral blood flow becomes dependent on the systemic blood pressure. A systolic blood pressure of 80 mm Hg will impair cerebral perfusion because calculation of the cerebral perfusion pressure is the mean arterial pressure minus the ICP.
B. A normal ICP reading is less than 15 mm Hg. A reading of 60 mm Hg is highly unlikely, given that brain herniation would have occurred.
C. A normal cerebral perfusion pressure should be 60 mm Hg or above; 30 mm Hg indicates neuronal hypoxia.
D. Mannitol, an osmotic diuretic, decreases cerebral edema by pulling fluid into the vasculature for elimination by the kidneys. Increased urinary elimination means there is decreased fluid in the intracranial cavity and a potential decrease in ICP because blood, brain volume, and cerebrospinal fluid are components that contribute to ICP.
Category: Neurological Emergencies, Neurogenic shock
Question 131
A patient presents to triage with complaints of left ankle pain after hearing a “popping” sound when they landed hard on the foot while playing basketball. The ankle is swollen and ecchymotic, and the patient has pain when bearing weight. The nurse recognizes that the most likely injury is which of the following?
Dislocation
Strain
Avulsion fracture
Sprain
✓
Correct Answer
Sprain
A. An avulsion fracture occurs when a muscle mass contracts forcefully, causing a bone fragment to tear off at the muscle insertion site. Ligaments can also tear fragments from bone. An X-ray would be needed to determine if this occurred.
B. A sprain is the result of injury to the ligaments that have been stretched or torn by excessive force. Ankle sprains are often associated with sports activities, and a popping sound or sensation is common with ligament injury. They are graded according to degree of damage and the amount of instability present.
C. Dislocation results from significant force to the affected joint. Ankle dislocation occurs with plantar flexion when the foot is inverted or diverted under stress and occurs more frequently in children and adolescents. Presence of neurovascular compromise is possible with a dislocation. Typically there is obvious deformity with dislocation.
D. A strain is the stretching or tearing of a muscle or tendon from bone as the result of excessive force. Strains are graded according to severity in a similar manner to sprains.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament
Question 132
Which of the following is considered a hallmark electrocardiogram change associated with hypothermia?
Pathologic Q-waves
ST elevation
T-wave inversion
J-wave
✓
Correct Answer
J-wave
A. T-wave inversion is seen with ischemia of the cardiac muscle.
B. Pathologic Q-waves indicate infarction of the heart muscle in the area associated with the appropriate lead changes.
C. ST elevation is noted as an injury pattern associated with acute myocardial infarction.
D. An Osborn or J-wave is a hallmark or characteristic electrocardiogram sign of hypothermia. This is seen as a small positive deflection between the QRS and the ST segment.
Category: Environment and Toxicology Emergencies, and Communicable
Question 133
Which of the following disorders would most likely occur in stage II of Lyme disease?
Atrioventricular blocks
✓
Fever
Bull’s-eye rash
Arthritis
Correct Answer
Atrioventricular blocks
A. Stage II of Lyme disease can present with disseminated disease processes such as atrioventricular blocks, meningitis, hepatitis, or cardiomyopathies. These occur starting at the fourth week of the disease and continue for up to 10 weeks.
B. The characteristic bull’s-eye rash is seen in stage I of Lyme disease. This stage usually lasts from 1 to 4 weeks after the tick bite.
C. Fever and other flulike symptoms occur in the first stage of Lyme disease, which can last from 1 to 4 weeks.
D. Chronic arthritis is one of the manifestations of stage III of Lyme disease. Other processes that can occur during this time include skin lesions, meningoencephalitis, myocarditis, and psychiatric manifestations. Stage III can last for years.
Category: Environment and Toxicology Emergencies, and Communicable
Question 134
The nurse is caring for a patient with a permanent pacemaker and observes that the patient has a paced rhythm with an occasional normal beat (patient’s own intrinsic beat without the presence of a pacemaker spike). The nurse would interpret this rhythm as:
paced rhythm with capture.
malfunctioning pacemaker.
paced rhythm with failure to sense.
paced rhythm with sensing.
✓
Correct Answer
paced rhythm with sensing.
A. A paced rhythm with capture would display a complex pattern immediately after the pacemaker spike. The pacemaker spike would occur with either a P-wave (atrial pacing), a QRS (ventricular pacing), or both (dual chamber or atrial/ventricular pacing).
B. Sensing is noted when the pacemaker recognizes the patient’s own intrinsic cardiac rhythm and does not fire, allowing the patient’s own cardiac cycle to occur. If the pacemaker discharges during the patient’s own cardiac cycle, a serious cardiac dysrhythmia could occur. Sensing is a safety feature for a pacemaker. The heart may only require the pacemaker intermittently, when the heart rate decreases below a predetermined rate. As the patient’s heart rate increases, a pacemaker can be programmed to sense the patient’s own cardiac rhythm and not emit an impulse.
C. A pacemaker can have the capability of sensing an intrinsic beat or intrinsic rhythm and ceasing to fire. This is a safety feature to prevent a demand pacemaker from firing during a cardiac cycle, possibly causing a lethal dysrhythmia. Emergency pacing using a transcutaneous pacemaker does not have this sensing capability.
D. If the pacemaker recognizes a cardiac cycle and does not discharge, the pacemaker is sensing and functioning normally. A malfunction occurs when the pacemaker fails to recognize the patient’s own intrinsic rhythm and continues to emit an impulse or pacer spike that has the potential to occur on the patient’s own T-wave, resulting in ventricular fibrillation.
Category: Cardiovascular Emergencies, Dysrhythmias
Question 135
A patient presents with complaints of generalized muscle spasms, pain, and headache. The patient reports stepping on a nail 2 days ago. Which bacterial organism does the nurse anticipate being the cause of the patient’s symptoms?
Clostridium tetani
✓
Group A Streptococcus
Staphylococcus aureus
Clostridium perfringens
Correct Answer
Clostridium tetani
A. Group A Streptococcus is found in the tissues of the throat and skin. The initial presentation of a Streptococcus infection includes fever, erythema, purulent discharge, or an abscess and may progress to necrotizing fasciitis. Infections from group A Streptococcus do not cause generalized muscle spasms.
B. Puncture wounds place the patient at risk for developing tetanus from the Clostridium tetani organism. Restlessness, muscle spasms, pain, and headache are initial symptoms of tetanus.
C. Staphylococcus aureus is a common causative agent for skin infections. The infection first appears as a localized abscess of the superficial subcutaneous tissues; the infection may also spread systemically.
D. Clostridium perfringens causes skin infections and gastrointestinal infections. It can cause gas gangrene, a tightening edema that results in hypoxia and crepitus of the soft tissues. Crepitus is the result of hydrogen sulfide and carbon dioxide within the tissue. A radiograph (X-ray) of the infected area will demonstrate the presence of gas bubbles within the tissue.
Category: Musculoskeletal and Wound Emergencies, Wound, Wound infections
Question 136
A patient arrives via emergency medical services with tonic–clonic seizures. Past medical history includes uncomplicated home delivery yesterday with a midwife, hypertension, and asthma. Which of the following medication interventions is the priority?
Labetalol
Lorazepam
Magnesium sulfate
✓
Nifedipine
Correct Answer
Magnesium sulfate
A. Based on history and symptoms, this patient is eclamptic. Approximately 80% of eclamptic seizures occur in the last trimester or within the first 48 hours after delivery. Magnesium sulfate is the recommended medication to control seizures with eclampsia. Start with a loading dose followed by a maintenance infusion.
B. Lorazepam is an anticonvulsant medication that may be used to treat eclamptic seizures only if magnesium sulfate is ineffective or contraindicated.
C. Labetalol is one of the first-line medications recommended for the treatment of severe-range maternal hypertension; however, it is contraindicated for patients with a history of asthma.
D. Nifedipine is one of the medications recommended for the treatment of severe-range hypertension, but it is an oral medication and would not be administered while the patient is actively seizing.
Category: Neurological Emergencies, Seizure disorders
Question 137
A patient newly diagnosed with multiple sclerosis (MS) arrives in the emergency department with complaints of urinary frequency and incontinence. Bladder infection was ruled out. The diagnosis is a sequela of their multiple sclerosis. Which of the following should be included in their discharge instructions?
Perform Kegel exercises
✓
Push fluids throughout the day
Use over-the-counter phenazopyridine hydrochloride
Increase caffeine intake
Correct Answer
Perform Kegel exercises
A. Approximately 80% of patients with MS have bladder control issues. In addition to fluid restriction at bedtime and avoiding caffeine, Kegel exercises are recommended to strengthen the pelvic floor muscles that support the bladder.
B. Approximately 80% of patients with MS have bladder control issues. Caffeine is considered a dietary irritant and can exacerbate the symptoms. It is recommended that caffeine be avoided.
C. Approximately 80% of patients with MS have bladder control issues. Pushing fluids would be recommend if the patient had a urinary tract infection; it is not needed in this instance.
D. Approximately 80% of patients with MS have bladder control issues. Over-the-counter phenazopyridine hydrochloride, commonly known as AZO, will not help with these symptoms.
Category: Neurological Emergencies, Neurological disorders (e.g., multiple
Question 138
A patient is being treated for aortic aneurysm dissection. The nurse reevaluates the patient following the ordered interventions. Which of the following assessment findings meets the goal of those interventions?
Systolic blood pressure of 128 mm Hg
Heart rate of 106 beats/minute
Glasgow Coma Scale score of 9
Urinary output of 0.7 mL/kg/hr
✓
Correct Answer
Urinary output of 0.7 mL/kg/hr
A. The goal of treatment is evidence of end-organ perfusion and prevention of extension of the dissection. Patients being treated for an aortic dissection should maintain a lower heart rate (less than 100 beats/minute) to avoid putting undue stress on the aorta, but still maintain adequate cardiac output.
B. The goal of treatment is evidence of end-organ perfusion and prevention of extension of the dissection. Patients with aortic dissection should have their systolic blood pressure maintained between 100 and 120 mm Hg to avoid putting undue stress on the aorta, but still maintain adequate cardiac output until definitive treatment can be given.
C. The goal of treatment is evidence of end-organ perfusion and prevention of extension of the dissection. A Glasgow Coma Scale score of 9 indicates decreased mentation and inadequate perfusion (7 or lower indicates coma). The goal would be for the patient to have normal or near-normal mentation and alertness.
D. The goal of treatment is evidence of end-organ perfusion and prevention of extension of the dissection. Normal urine output is 0.5–1.0 mL/kg/hr and is a good indicator of end-organ perfusion.
Category: Cardiovascular Emergencies, Aneurysm and dissection
Question 139
A patient with a recent diagnosis of myasthenia gravis arrives in the emergency department. During triage, which of the following symptoms is most concerning for this patient?
Nausea and vomiting
Abdominal cramps
Muscle twitching
Muscle weakness
✓
Correct Answer
Muscle weakness
A. Muscle weakness can be a sign of myasthenic crisis or cholinergic crisis and is usually a precursor to respiratory failure. Myasthenic crisis is often preceded by infection, stress, or certain medications. Cholinergic crisis is usually related to overdose of cholinesterase inhibitor medications. Close observation of increasing fatigue and respiratory status is necessary, and intubation may be required.
B. Nausea and vomiting can be a side effect of new medications started for myasthenia gravis or a sign of cholinergic crisis. Muscle fatigue is more concerning because it is usually a precursor to respiratory failure for these patients.
C. Abdominal cramps can be a side effect of new medications started for myasthenia gravis or a sign of cholinergic crisis. Muscle fatigue is more concerning because it is usually a precursor to respiratory failure for these patients.
D. Muscle twitching can be a side effect of new medications started for myasthenia gravis or a sign of cholinergic crisis. Muscle fatigue is more concerning because it is usually a precursor to respiratory failure for these patients.
Category: Neurological Emergencies, Neurological disorders (e.g., multiple
Question 140
A patient is being treated with nitroglycerin for an acute myocardial infarction. Which of the following is an expected outcome of the medication?
Increased afterload
Decreased coronary blood flow
Increased myocardial consumption
Decreased preload
✓
Correct Answer
Decreased preload
A. Nitrates dilate the venous system and decrease venous return to the heart (preload), making it easier for the heart to contract.
B. Nitrates dilate arterial vessels and lower systemic blood pressure (afterload), leading to a decreased resistance to ventricular emptying.
C. Nitrates relax vascular smooth muscle, including the coronary arteries, and improve coronary blood flow.
D. Nitrates dilate venous and arterial vessels and decrease the work of the heart, leading to a decrease in myocardial oxygen consumption.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 141
An unresponsive male patient arrives via emergency medical services following a motor vehicle collision. On patient assessment, priapism is noted. Based on this finding, what is the priority intervention?
Prepare the patient for an abdominal ultrasound
Insert a urinary drainage catheter
Ensure cervical spinal immobilization
✓
Obtain intravenous (IV) access and begin fluid resuscitation
Correct Answer
Ensure cervical spinal immobilization
A. Priapism is a urological emergency that can occur as a result of a spinal cord injury, a tumor, sickle cell disease, or the ingestion of phosphodiesterase inhibitors. The mechanism of injury in this patient, along with his inability to respond to commands, would lead the nurse to suspect a spinal cord injury.
B. The etiology of priapism is not related to urinary retention; the insertion of a urinary catheter by the nurse can result in urethral damage.
C. Preparing the patient for an abdominal ultrasound is not appropriate at this time. Priapism does not occur as a result of intra-abdominal injury or other pathology.
D. Obtaining IV access and beginning fluid resuscitation may be indicated for this patient; however, when a spinal cord injury is suspected, the priority is to ensure cervical spinal immobilization.
Category: Neurological Emergencies, Head and spinal cord trauma
Question 142
The nurse is caring for a patient with increased intracranial pressure (ICP) due to a subarachnoid hemorrhage. The provider has ordered hyperosmolar therapy to reduce ICP. This therapy works through which of the following mechanisms?
Decreases water from cerebral tissues
✓
Increases cerebral blood volume
Decreases plasma volume
Increases blood viscosity
Correct Answer
Decreases water from cerebral tissues
A. Hyperosmolar therapy reduces ICP by expanding plasma volume.
B. Hyperosmolar therapy reduces ICP by decreasing blood viscosity.
C. Hyperosmolar therapy reduces ICP by decreasing cerebral blood volume.
D. Hyperosmolar therapy reduces ICP by creating an osmotic gradient that pulls water from the cerebral tissue into the vascular space.
Category: Neurological Emergencies, Increased intracranial pressure (ICP)
Question 143
A patient presents to triage stating that he felt a “pop” in his head after lifting heavy weights. The patient now complains of a right-sided headache that he rates as a 10 out of 10 on the pain scale. The nurse notes that the patient’s right pupil is oval and sluggishly reactive to light. What priority action will the nurse take next?
Place the patient in the waiting room until a room becomes available
Complete the medical screening exam in triage
Proceed with immediate bedding in the ED
✓
Place the patient in fast-track/minor care area
Correct Answer
Proceed with immediate bedding in the ED
A. Subarachnoid hemorrhages typically occur in younger males and may be associated with a strenuous act. Pupillary changes are typically ipsilateral in the presence of a subarachnoid hemorrhage and result from compression of cranial nerve III. This patient has a potentially life-threatening injury and should be immediately placed in an emergency bed to be seen and evaluated.
B. This patient will require an immediate computed tomography scan of the head and is not an appropriate candidate for fast-track care.
C. This patient will require an immediate computed tomography scan of the head and should not be sent to the waiting room.
D. This patient will require an immediate computed tomography scan of the head, and care should not be delayed for a medical screening exam in triage.
Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)
Question 144
Which is the priority assessment that should be performed on a 26-week-pregnant female who presents with a tonic–clonic seizure?
Fetal heart monitoring
✓
Measurement of fundal height
Pelvic ultrasound
Measurement of abdominal girth
Correct Answer
Fetal heart monitoring
A. Continuous electronic fetal heart monitoring provides an overall view of maternal–fetal well-being. The maternal patient must maintain compensated respiratory alkalosis for the placenta to carry oxygen to the fetus. The mother may have experienced respiratory acidosis during the seizure, which could result in decreased oxygenation to the developing fetus. A drop in fetal heart rate or decelerations during contractions may indicate the need for emergency cesarean section.
B. Measurement of abdominal girth is not an important assessment in maternal seizures.
C. Although useful, an ultrasound will not provide an up-to-date, continuous picture of maternal–fetal well-being and would not be done until after the seizure subsides.
D. The measurement of fundal height may be helpful to predict gestational age and viability, but it is not an important assessment in maternal seizures.
Category: Neurological Emergencies, Seizure disorders
Question 145
An adult presents to triage with fever, severe headache, petechial rash, and stiff neck. What is the priority medication for this patient?
Antibiotics
✓
Antipyretics
Pain medication
Osmotic diuretics
Correct Answer
Antibiotics
A. Based on the identified symptoms, the patient most likely has meningitis. The priority treatment for a patient with meningitis is the prompt administration of antibiotics. Lumbar puncture should be completed prior to administration when possible.
B. Antipyretics are used for fever control; this may be an appropriate medication for this patient, but it is not the priority.
C. Pain is often associated with meningitis, but the priority is treatment of infection with the administration of antibiotics.
D. Osmotic diuretics are not an appropriate medication in the treatment of meningitis. The priority for this patient is the prompt administration of antibiotics.
Category: Neurological Emergencies, Meningitis
Question 146
Clevidipine (Cleviprex) infusion is ordered for a symptomatic patient with severe hypertension. The nurse is aware that this medication would be contraindicated in a patient with which history?
Sinus bradycardia
Recent use of sildenafil
Soybean or egg allergy
✓
Asthma
Correct Answer
Soybean or egg allergy
A. Clevidipine is a calcium channel blocker used for blood pressure reduction. It is a lipid emulsion and is contraindicated in patients with allergies to soybeans, soy products, eggs, or egg products. Defective lipid metabolism is another contraindication. Strict aseptic technique should be followed, and unused medication should be discarded within 12 hours of puncturing the stopper.
B. Asthma is a contraindication for labetalol administration, but not for the administration of clevidipine.
C. Sinus bradycardia is a contraindication for esmolol and labetalol administration, but not for the administration of clevidipine.
D. Recent (last 24 hours) use of sildenafil is a contraindication for nitroglycerine administration, but not for the administration of clevidipine.
Category: Cardiovascular Emergencies, Hypertension
Question 147
Which of the following findings would the nurse anticipate in a patient with pericardial tamponade following successful aspiration of fluid from the pericardial sac?
Presence of electrical alternans
Increase in the patient’s blood pressure
✓
Presence of pulsus paradoxus
Increase in the patient’s heart rate
Correct Answer
Increase in the patient’s blood pressure
A. Electrical alternans is a finding in the presence of cardiac tamponade and is characterized by the alternating amplitude of each QRS complex. This is a diagnostic finding in the presence of cardiac tamponade and should not be present after the tamponade has been eliminated.
B. An elevated or increased heart rate would be evident in the presence of pericardial tamponade because of decreased cardiac filling; however, following removal of fluid from the pericardial sac, the heart rate should lower.
C. Pulsus paradoxus is a systolic blood pressure drop of more than 10 mm Hg during inspiration. It occurs when there are alterations in the mechanical forces on the heart and pulmonary vessels. Once fluid is removed from the sac, this should no longer be present.
D. Following removal of fluid from the pericardial sac, the patient’s central venous pressure should decrease, allowing for increased preload and an increase in the patient’s blood pressure.
Category: Cardiovascular Emergencies, Pericardial tamponade
Question 148
A patient is being treated for an acute myocardial infarction with signs of cardiogenic shock. Assessment shows a patient in severe distress, with HR 110 beats/minute; BP 60/40 mm Hg; and RR 36 breaths/minute and bilateral rales. Based on this patient’s degree of hypotension, what would be the vasopressor of choice?
Norepinephrine
✓
Dobutamine
Vasopressin
Dopamine
Correct Answer
Norepinephrine
A. Initial use of norepinephrine (Levophed) for marked hypotension, < 70 mm Hg systolic, is the current recommendation from the American Heart Association and the American College of Cardiology.
B. Dopamine (Intropin) has been associated with a higher risk of death and arrhythmia in the setting of hypotensive cardiogenic shock.
C. Dobutamine (Dobutrex) is a positive inotrope, but its vasodilatory effects may make its use limited in hypotensive cardiogenic shock.
D. Vasopressin (Pitressin) is a useful adjunctive drug along with norepinephrine in the setting of refractory hypotensive cardiogenic shock.
Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock
Question 149
A patient sustained an amputation of the index finger from having it caught in a car door. What is the correct method to care for the amputated part?
Wrap with sterile gauze soaked in tap water, place the part in a sealed bag, place the sealed bag in another bag, and place in tepid water
Wrap in sterile gauze slightly moistened with saline, place the wrapped part in a sealed plastic bag, and place the sealed bag in a second bag with ice and water
✓
Wrap with dry sterile gauze, place the part in a sealed bag, place the sealed bag in another bag, and place in tepid water
Wrap in sterile gauze soaked with an antimicrobial soap and saline, place the part in a sealed bag, place the sealed bag in another bag, and place in ice water
Correct Answer
Wrap in sterile gauze slightly moistened with saline, place the wrapped part in a sealed plastic bag, and place the sealed bag in a second bag with ice and water
A. The amputated part should not be wrapped with gauze in tap water, and it should be placed on ice. Numerous organisms in tap water can lead to infection and prevent successful reimplantation of the amputated part.
B. Antimicrobial soap can damage the soft tissue of the amputated part and prevent reimplantation.
C. The amputated part should not be allowed to dry out and should be kept cooled.
D. For best results regarding successful reimplantation of an amputated part, it is best to keep the amputated part wrapped in sterile gauze that has been slightly moistened with sterile saline, and place it in a dry plastic bag. That bag should be placed in a second plastic bag with 1/2 water and 1/2 saline. Care should be taken to avoid submerging the amputated part in fluid and to keep the amputated part from direct contact with ice to avoid freezing.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Amputation
Question 150
A patient was splashed in the face and eyes with cleaning solution. Which of the following assessments would indicate that effective eye irrigation has occurred?
Clear sclera was noted after irrigation.
Eye pH of 7.25 was achieved after irrigation.
✓
Visual acuity of 20/20 is documented after irrigation.
A total of 1.0 L of dextrose and water was used for irrigation.
Correct Answer
Eye pH of 7.25 was achieved after irrigation.
A. Irrigation may need to continue for up to 60 minutes or longer and is not limited to 1.0 L. Appropriate irrigation fluids are normal saline and Ringer’s lactate solution, not dextrose-containing fluids.
B. If possible, a pH value of the eye should be obtained before starting irrigation and repeated after copious eye irrigation has been completed. The irrigation should be continued until the eye pH is between 7.0 and 8.0 (the pH of tears is 7.4). A waiting period of at least 5 minutes should occur after stopping irrigation so that the pH of the eye is obtained, rather than the pH of the fluid used for the irrigation. For alkaline burns, irrigation should continue until a pH of 7.5–8.0 is obtained.
C. The sclera may appear injected or reddened because of irritation from the irrigation or chemical injury and should not be a determinant to discontinue irrigation. Eye pH should be the guide for discontinuing the irrigation.
D. Although a visual acuity of 20/20 is normal, it would not be an indicator that eye irrigation should be discontinued. The pH of tears is 7.4, and irrigation should be continued until a pH of 7.0–8.0 is maintained.
Category: Environment and Toxicology Emergencies, and Communicable