A patient is noted to have red, painless spots on the palms and soles, red, painful nodes in the pad of the fingers and toes, and splinter hemorrhages under the nails, as well as an elevated body temperature and elevated white blood cell (WBC) count. The emergency nurse suspects the patient has:
leukemia
pericarditis
endocarditis
✓
myocarditis
Correct Answer
endocarditis
A. The patient’s symptoms are classic for endocarditis. Petechial lesions found on the palms of the hands or soles of the feet are known as Janeway lesions. Painful fingertip nodes or lesions are known as Osler’s nodes. The patient may experience fevers along with an elevated WBC count. Endocarditis is a bacterial infection; possible causes include a damaged or abnormal heart valve, parenteral drug addiction, and long-term IV access. The endocarditic infection may also spread to valve structures in the heart, resulting in permanent valvular dysfunction.
B. Pericarditis, or inflammation of the pericardial sac, is characterized by an elevation in WBC count, a pericardial friction rub, and ST changes throughout the electrocardiogram. Pericarditis is not associated with the presence of Janeway lesions.
C. Myocarditis, or inflammation of the cardiac muscle, is characterized by chest pain, cardiac rhythm abnormalities, poor nutrition, and fatigue. Myocarditis is typically a viral infection that presents with fevers and elevated WBC count.
D. Leukemia, or cancer of the blood system, is diagnosed by abnormalities in WBC counts. A rash may also be present with certain types of leukemia.
Category: Cardiovascular Emergencies, Endocarditis
Question 2
A conscious pulseless patient with a continuous-flow left ventricular assist device and a history of end-stage heart failure presents to the emergency department because of a “low-flow” alarm. Which of the following interventions would be appropriate in this scenario?
Obtain an automatic blood pressure
Exchange the controller
Begin chest compressions
Administer intravenous fluids
✓
Correct Answer
Administer intravenous fluids
A. With no palpable pulse, obtaining a mechanical blood pressure is usually not feasible. A mean arterial blood pressure (MAP) should be obtained by placing a Doppler over the brachial or radial artery and then inflating the cuff until flow is no longer heard. Once the arterial flow is heard again, this is the MAP. Left ventricular assist device (LVAD) patients should have MAPs between 70 and 80 mm Hg. In a conscious patient, determining the patient’s blood pressure will help guide therapy and troubleshooting. The patient’s LVAD coordinator should also be contacted as soon as possible.
B. The controller should be changed only in consultation with a trained professional from the VAD team. Patients are instructed to carry a backup controller in case of malfunction.
C. Fluids should be initiated. The “low-flow” alarm may be due to decreased preload from hypotension, dehydration, obstruction of the inflow or outflow (which would cause an increase in afterload) cannula, or disconnection of percutaneous leads. In a stable patient, the provider should focus efforts on identifying the potential causes of the alarm.
D. Chest compressions are not indicated in a conscious patient. Patients with continuous-flow LVADs often do not have a palpable pulse because the device is pumping constantly throughout the cardiac cycle; this causes aortic flow to be present during diastole, leading to reduced pulse pressure. Chest compressions may be indicated if a patient with an LVAD is unconscious, pulseless, and intubated with a PetCO2 < 20 mm Hg because this may indicate severely impaired systemic perfusion.
Category: Cardiovascular Emergencies, Heart failure
Question 3
A nurse is preparing to assist with drug-assisted intubation (DAI) for a patient in severe respiratory distress with a pulse oximetry reading of 91%. Which of the following is the priority intervention for preoxygenating the patient?
Place the patient in reverse Trendelenburg
Administer an opioid
Provide high-flow oxygen
✓
Use positive pressure ventilation
Correct Answer
Provide high-flow oxygen
A. If a patient is on a spine board, placing in them in reverse Trendelenburg position may help prevent oxygen desaturation during intubation. This is not a trauma patient, so this is not the priority intervention in this scenario.
B. Administration of medications to mitigate adverse effects occurs during the pretreatment phase of DAI. Administering an opioid before intubation may reduce myocardial oxygen consumption and pulmonary artery pressure that might increase from intubation; however, this practice is evaluated on a case-by-case basis and not recommended routinely.
C. Assisted ventilation with a bag-mask device is not recommended because of the risk for aspiration. Positive pressure ventilation may be indicated during the preoxygenation phase of DAI for those patients unable to achieve an oxygen saturation at or above 94%. This is not the priority intervention in this scenario.
D. Providing high-flow oxygen at the highest concentration available will prepare the patient to tolerate the period of apnea and prevent oxygen desaturation during intubation. This is the priority intervention during the preoxygenation phase of DAI.
Category: Respiratory Emergencies, Respiratory distress syndrome
Question 4
A patient presents complaining of lower abdominal pain and the inability to void in the past 24 hours. Which of the following is the priority intervention for this patient?
Preparing the patient for an abdominal radiograph
Obtaining a full set of vital signs
Inserting a urinary catheter
✓
Administering an intravenous fluid bolus of 500 mL
Correct Answer
Inserting a urinary catheter
A. Although vital signs are important, relieving bladder pressure is the priority.
B. Computed tomography or abdominal x-ray may be needed to rule out bladder calculi, which is one of several etiologies that may be responsible for urinary retention; however, the priority intervention is to relieve the bladder pressure and prevent bladder rupture.
C. The priority intervention should be to relieve pressure within the bladder and prevent bladder rupture. This is accomplished by the insertion of an indwelling urinary catheter.
D. A lack of urinary output may be related to fluid volume status; however, the patient’s absolute inability to void, along with lower abdominal discomfort, strongly suggests that urinary retention, not hypovolemia, is the underlying problem to be addressed.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Genitourinary, Urinary retention
Question 5
An emergency department patient has been diagnosed with a subarachnoid hemorrhage (SAH). Which medication is the priority for this patient?
Antihypertensive
✓
Calcium channel blocker
Antiemetic
Antiepileptic
Correct Answer
Antihypertensive
A. Patients with a SBP > 160 are more likely to suffer rebleeding. Over 40% of patients with SAH in the ED have a SBP > 185, so prompt reduction and management of blood pressure is critical. Although antiemetics are useful in treating nausea and vomiting and avoiding a Valsalva effect, which can raise intracranial pressure, they are not the priority.
B. Patients with a SBP > 160 are more likely to suffer rebleeding. Over 40% of patients with SAH in the ED have a SBP > 185, so prompt reduction and management of blood pressure is critical. Antiepileptics should be considered to prevent seizures associated with increased ICP.
C. Patients with a SBP > 160 are more likely to suffer rebleeding. Patients who rebleed tend to have a poor outcome. Over 40% of patients with SAH in the ED have a SBP > 185, so prompt reduction and management of blood pressure is critical.
D. Patients with a SBP > 160 are more likely to suffer rebleeding. Over 40% of patients with SAH in the ED have a SBP > 185, so prompt reduction and management of blood pressure is critical. Oral nimodipine is a calcium channel blocker often used to prevent vasospasm, which is a complication after SAH.
Category: Neurological Emergencies, Stroke
Question 6
A patient has experienced an acute psychotic episode and states, “I’m coming back here when I get released from the hospital, and I am going to kill Jane Smith.” Which of the following interventions would be most appropriate for a nurse to perform?
Alert the proper law enforcement authorities
✓
Ignore the threat because this is normal behavior in patients who are psychotic
Tell the patient that it is inappropriate to make this statement
Request that the hospital chaplain come and talk to the patient
Correct Answer
Alert the proper law enforcement authorities
A. It would be egregious to ignore something of this nature and not report the threat to both the proper authorities and the individual being named.
B. It is important that the proper authorities be notified when patients make statements that are very specific in nature and when they name a particular person. That person should be aware of the threat and provided the proper protection.
C. Informing the patient that this is inappropriate will provide no protective care to the individual named and would not be of any benefit to the patient in their current mental state of being.
D. The hospital chaplain would not be an appropriate person to intervene and speak to the patient regarding the threat they have made. This could be an idle threat, or it could be real. It is not appropriate for nonmedical individuals to determine whether the patient’s threat is real.
Category: Mental Health Emergencies, Homicidal and suicidal ideation
Question 7
Heparin may be administered to prevent the formation of clots in disseminated intravascular coagulation (DIC) associated with which of the following conditions?
Recent hip surgery
Retained placenta
✓
Ruptured cerebral aneurysm
Gastrointestinal bleeding
Correct Answer
Retained placenta
A. Though heparin is not used often to treat DIC, it has shown benefits in some obstetric-related cases, such as retained placenta and incomplete abortion.
B. Though heparin is not used often to treat DIC, it has shown benefits in some obstetric-related cases, such as retained placenta and incomplete abortion. It is contraindicated with gastrointestinal bleeding.
C. Though heparin is not used often to treat DIC, it has shown benefits in some obstetric-related cases, such as retained placenta and incomplete abortion. It is contraindicated if there has been recent surgery.
D. Though heparin is not used often to treat DIC, it has shown benefits in some obstetric-related cases, such as retained placenta and incomplete abortion. It is contraindicated if there is central nervous system bleeding.
Category: Medical Emergencies, Hematologic disorders
Question 8
The nurse is preparing to discharge a female geriatric patient who presented for severe “heartburn.” Medication reconciliation reveals that the patient is on alendronate (Fosamax). What information should the nurse provide to the patient with the discharge instructions?
Take alendronate at bedtime
Always take alendronate with food
Sit or stand upright for 30 minutes after taking alendronate
✓
Have calcium blood levels monitored monthly
Correct Answer
Sit or stand upright for 30 minutes after taking alendronate
A. The patient should be instructed to take the medication on an empty stomach with a full glass of water to promote absorption of the drug, and to avoid eating and drinking for 30 minutes after taking it.
B. A side effect of alendronate is esophageal irritation, so the patient must remain upright for 30 minutes after taking the medication. In severe cases, esophageal irritation can result in esophageal erosion.
C. Alendronate is a bisphosphonate that works by inhibiting the resorption of the bone and increasing bone mass. Calcium levels need to be monitored in patients taking hormones such as calcitonin and teriparatide.
D. Alendronate is to be taken 30 minutes before meals and should not be taken at bedtime. A side effect of alendronate is esophageal irritation, so the patient must remain upright for 30 minutes after taking the medication.
Category: Professional Issues, Patient, Discharge planning
Question 9
A patient presents to triage with complaints of a severe throbbing-type headache pain above the left eye and the left side of the face. The patient has a history of polymyalgia rheumatica. The nurse suspects that the patient’s current discomfort is related to the presence of which of the following?
Sinusitis
Temporomandibular joint (TMJ) dislocation
Cluster headache
Temporal arteritis
✓
Correct Answer
Temporal arteritis
A. TMJ dislocation is a displacement of the mandibular condyle that results in spasms and muscle contraction of the jaw muscles, so the condyles cannot return to their normal position. TMJ dislocation can occur as a result of trauma or from simply opening the mouth too wide for extended periods, such as during dental work.
B. Temporal arteritis is also referred to as systemic arterial vasculitis or giant cell arteritis and produces a severe frontal throbbing type of pain. Palpation over the temporal region results in severe discomfort for the patient. Patients who experience temporal arteritis may have a history of polymyalgia rheumatica and are usually over the age of 50.
C. Cluster headaches affect men more than women and are related to a dysfunction of the trigeminal nerve. The headache is characterized by an intense unilateral pain in the orbital or temporal region that lasts from 15 minutes to 3 hours.
D. Sinusitis results from the blockage of drainage from the paranasal sinuses. It can be caused by a recent upper respiratory infection or allergic rhinitis. The headache is typically bilateral and is described as dull achy discomfort over the affected sinus.
Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)
Question 10
An unresponsive patient arrives at the ED with upper- and midfacial injuries after involvement in a high-speed motor vehicle collision. Which of the following interventions should be used initially to maintain an open airway for this patient?
Use the head tilt–chin lift maneuver
Intubate with an uncuffed endotracheal tube
Place the patient in a left lateral position
Insert an oropharyngeal airway
✓
Correct Answer
Insert an oropharyngeal airway
A. This patient will probably need a definitive airway, but a cuffed tube is recommended for all patients.
B. This patient is unresponsive and has midfacial injuries, so an oropharyngeal airway would be used. A nasopharyngeal airway should not be used for this patient because there is a possibility of facial fractures. This is a temporary measure until a definitive airway can be established or the patient becomes conscious.
C. Placing the patient into a left lateral position should not be performed until the presence or absence of a cervical spine injury can be determined.
D. With an unresponsive patient, the jaw-thrust maneuver, not the head tilt–chin lift maneuver, should be used to open the airway until cervical spine injury has been ruled out. Someone would also need to maintain the position to keep the airway open.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Maxillofacial trauma
Question 11
A patient is being treated in the emergency department for suicidal ideation. The patient lives alone, recently lost their job, and will soon lose their apartment. The patient has been talking to friends about not being around and admits to having a plan. Which of the following is the most appropriate disposition for this patient?
Inpatient admission to an intensive care unit
Discharge to home and follow up with primary care
Inpatient admission to a psychiatric unit
✓
Discharge to a friend’s home with outpatient counseling
Correct Answer
Inpatient admission to a psychiatric unit
A. This patient is considered a high risk for suicide because of multiple risk factors (job loss, loss of home, saying they won’t be around, and having a plan). The patient should be admitted until they are more stable and an appropriate follow-up plan can be developed.
B. Discharge to home is not appropriate for this patient. The patient is high risk and needs monitoring in an inpatient psychiatric setting. This patient will need follow-up with counseling and other psychiatric services.
C. This patient does not need admission to an intensive care unit. There is no medical reason for the admission. Discharge to home is not appropriate for this patient. The patient is high risk and needs monitoring in an inpatient psychiatric setting. This patient will need follow-up with counseling and other psychiatric services.
D. Discharge to a friend’s home is not appropriate for this patient. The patient is high risk and needs monitoring in an inpatient setting. This patient will need follow-up with counseling and other psychiatric services.
Category: Mental Health Emergencies, Homicidal and suicidal ideation
Question 12
A patient involved in a motor vehicle collision is diagnosed with an unstable pelvic ring fracture. Which classification of hypovolemic shock would most likely occur as a result of this injury?
Class I
Class II
Class III
Class IV
✓
Correct Answer
Class IV
A. Class IV hypovolemic shock occurs with blood loss greater than 2000 mL or 40% of total blood volume. The human body has approximately 5 L of blood. Estimated blood loss from an unstable pelvic ring fracture is > 3000 mL. Severe signs and symptoms of hypovolemia would be present.
B. Class III hypovolemic shock is defined as blood loss of 1500–2000 mL or 30–40% of total blood volume. With a possible blood loss of > 3000 mL from the fractured pelvis, the blood loss would be well beyond the Class III category.
C. Class II hypovolemic shock is defined as blood loss of 750–1500 mL or 15–30% of total blood volume. The anticipated blood loss from this pelvic fracture would exceed this classification.
D. Class I hypovolemic shock is defined as blood loss up to 750 mL or less than 15% of total blood volume. The anticipated blood loss from this pelvic fracture would greatly exceed this classification.
Category: Medical Emergencies, Hypovolemic and distributive shock
Question 13
A nurse is caring for a patient in asystole during cardiopulmonary resuscitation, and intravenous access cannot be obtained. The physician orders intravenous epinephrine. What is the most appropriate nursing action at this time?
Wait until intravenous access is obtained before preparing the dose
Recommend administering the epinephrine via the intraosseous route
✓
Recommend administering the epinephrine via the intramuscular route
Prepare to deliver an unsynchronized defibrillation at 120 joules
Correct Answer
Recommend administering the epinephrine via the intraosseous route
A. When intravenous access is not available, it is recommended that medications be given via the intraosseous route. Review your hospital policies and procedures on the process for completing this task.
B. The endotracheal route is safe for certain ACLS medications.
C. Defibrillation is not an appropriate intervention for a patient in asystole.
D. The intramuscular route is not approved for patients during cardiopulmonary resuscitation.
Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 14
A trauma patient has penetrating injuries to the anterior chest and abdomen. Further assessment reveals muffled heart sounds and distended neck veins. What is the most appropriate intervention at this time?
Decrease the intravenous flow rate to avoid hypervolemia
Prepare for a needle decompression at the second intercostal space midclavicular line
Prepare for chest tube insertion at the fifth intercostal space
Prepare for a needle aspiration to be inserted 1 cm left of the xiphocostal angle
✓
Correct Answer
Prepare for a needle aspiration to be inserted 1 cm left of the xiphocostal angle
A. Muffled heart sounds and distended neck veins are classic signs of pericardial (cardiac) tamponade. Pericardiocentesis is a procedure in which a needle is inserted 1 cm inferior to the left xiphocostal angle to aspirate the fluid that is filling the pericardial sac. It is a temporizing procedure to remove fluid while waiting for operative management.
B. Muffled heart sounds and distended neck veins after a penetrating chest trauma are highly suggestive of pericardial tamponade. Treatment should be focused on restoring cardiac output and hemodynamic stability. Decreasing the flow rate would not meet this goal.
C. Insertion of a 14-gauge needle into the second intercostal space midclavicular line on the affected side is the recommended treatment for immediate decompression of a tension pneumothorax.
D. Chest tube insertion at the fifth intercostal space at the anterior or midaxillary line is the treatment for a hemothorax.
Category: Cardiovascular Emergencies, Pericardial tamponade
Question 15
What is the best position to place a patient in order to auscultate for the presence of a pericardial friction rub?
Ask the patient to lie or sit quietly, and then place the stethoscope at the apex of the heart and listen for radiation to the axilla
Ask the patient to stand up and then squat, and then place the stethoscope at the left sternal border and listen at midsystole
Ask the patient to lean forward, and then place the stethoscope at the left sternal border and listen at end-expiration
✓
Ask the patient to lie or sit quietly, and then place the stethoscope at the right sternal border and listen for radiation to the neck
Correct Answer
Ask the patient to lean forward, and then place the stethoscope at the left sternal border and listen at end-expiration
A. The murmur in a patient with hypertrophic cardiomyopathy will decrease with a change from standing to squatting and peak at midsystole, and an S4 gallop may also be present.
B. The harsh crescendo–decrescendo murmur in a patient with aortic stenosis is best heard at the right sternal border with radiation to the neck.
C. It has been reported that up to 85% of patients with pericarditis will have a friction rub. Although the presence of a friction rub during the initial evaluation of a patient with pericarditis is unreliable, when present, it is best heard while the patient is leaning forward, with the stethoscope placed at the left sternal boarder at end-expiration. The sound that is made when inflamed layers of the pericardium rub against each other is thought to be the cause of the friction rub.
D. The pansystolic blowing murmur in a patient with mitral regurgitation is best heard at the apex and radiates to the axilla.
Category: Cardiovascular Emergencies, Pericarditis
Question 16
Which of the following statements made by a patient recently diagnosed with peripheral vascular disease indicates that they have an accurate understanding of the disease?
“I will limit my cigarette smoking to a half-pack a day.”
“When my leg starts to cramp, I should stop walking and rest.”
✓
“When pain develops in my leg, I should apply an ice pack.”
“When my leg starts to cramp, I should elevate it on two pillows.”
Correct Answer
“When my leg starts to cramp, I should stop walking and rest.”
A. Pain from peripheral vascular disease (PVD) can develop while exercising, experiencing stress, and being in a cold environment. It can be relieved by removing or discontinuing the cause.
B. Pain is exacerbated by a cold environment; a warm environment will help relieve the pain. Application of a direct heat source to the ischemic area could result in further harm to tissue.
C. The affected limb should not be elevated above the level of the heart; this will result in increased pain and cramping because peripheral blood flow to that area has been decreased.
D. Cigarette smoking has been identified as a major risk factor for the development of PVD. Other risk factors include hypertension, hyperlipidemia, diabetes, obesity, and a sedentary lifestyle.
Category: Cardiovascular Emergencies, Peripheral vascular disease
Question 17
Which of the following patients would be most at risk for developing a deep vein thrombosis (DVT) and pulmonary embolus (PE)?
A 26-year-old postpartum obese female
✓
A 48-year-old diabetic male
A 57-year-old male with controlled hypertension
A 55-year-old female with varicose veins
Correct Answer
A 26-year-old postpartum obese female
A. Virchow’s triad consists of factors that increase the risk of a person developing DVT: hypercoagulability, venous stasis, and endothelial injury. Chronic, uncontrolled hypertension can contribute to endothelial injury, which is a risk factor for developing DVT and PE. However, this patient’s hypertension is controlled and so lowers his risk for developing a DVT and PE.
B. Increased risk of hospitalization that is due to diabetes may result in venous stasis, which is a risk factor. However, research shows that diabetes mellitus is not an independent risk factor for DVT. This patient is not the most likely to develop a DVT and PE.
C. The obese patient has delayed venous return resulting from increased intra-abdominal pressure, creating a high risk for DVT and PE. Also, the patient is postpartum; this increases her risk because recent pregnancy results in a hypercoagulable state, which is a contributing factor to developing DVT and PE.
D. Research shows that patients with varicose veins have an increased risk of developing DVT. However, there is not enough evidence to support that varicose veins increase the risk of developing PE. This patient is not the most likely to develop a DVT and PE.
Category: Cardiovascular Emergencies, Thromboembolic disease (e.g., deep vein thrombosis [DVT])
Question 18
A patient with a stab wound to the left parasternal anterior chest is intubated and becomes pulseless shortly after arrival. Cardiopulmonary resuscitation is initiated. What is the priority intervention for this patient?
Open thoracotomy
✓
Point-of-care cardiac ultrasound
Needle pericardiocentesis
Chest radiograph
Correct Answer
Open thoracotomy
A. Ultrasound at the bedside may be helpful in the diagnosis of life-threatening injuries such as pericardial tamponade but will only delay the initiation of a potentially lifesaving open emergency department thoracotomy.
B. A chest radiograph may help define the presence of pneumothorax, hemothorax, or retained foreign objects but delays the initiation of an open emergency department thoracotomy.
C. Patients with low-velocity penetrating chest trauma with loss of signs of life on or just before arrival to the emergency department have the best chance of survival with an open emergency department thoracotomy.
D. Needle pericardiocentesis is often ineffective in relieving traumatic pericardial tamponade and delays the initiation of an open emergency department thoracotomy.
Category: Cardiovascular Emergencies, Cardiovascular trauma
Question 19
Following the insertion of an intraosseous (IO) device, which of the following findings would indicate that the IO has been properly placed?
The fluid infusion is halted when the tissue around the IO device is compressed.
Bright red blood is noted in the cannula after insertion.
A reddish frothy aspirate is noted after insertion.
✓
The needle has slight movement after insertion.
Correct Answer
A reddish frothy aspirate is noted after insertion.
A. No movement should occur after the IO device is placed in the bone. Movement of the IO device could indicate improper placement, or the insertion hole in the bone has been drilled too large for the device to be secure.
B. Bone marrow is reddish and frothy, not bright red blood. Blood present in the cannula could indicate unintentional placement of the IO needle into a blood vessel.
C. When the tip of the IO needle is erroneously positioned in the soft tissue, external pressure, such as that from squeezing the involved limb, will cause an increase in pressure transmitted to the attached syringe or tubing.
D. As the IO device is inserted, marrow may be aspirated. Bone marrow is a reddish frothy substance. During emergent situations, the aspirated marrow may be used for some laboratory testing.
Category: Cardiovascular Emergencies, Cardiovascular trauma
Question 20
A nurse is discharging a child with asthma with a peak expiratory flow meter. What instructions should be included in the teaching plan?
Inhale slowly and consistently
Blow forcefully into the mouthpiece
✓
Perform the test only once per day
Use only in times of symptoms
Correct Answer
Blow forcefully into the mouthpiece
A. The correct procedure to use the peak expiratory flow meter is to stand if able, inhale deeply, and forcefully exhale into the mouthpiece. The intention is for patients to identify their baseline respiratory function so they can monitor and prevent sudden attacks.
B. The device that is used to inhale deeply and consistently is an incentive spirometer, not the peak expiratory flow meter.
C. This device should be used daily to monitor respiratory function in order to identify respiratory decline or asthma triggers. By doing so, patients are able to alter their medication regimen to prevent an attack.
D. The test should be performed three times daily, with the highest value being recorded in the diary. The three exhalations should be performed one after the other.
Category: Respiratory Emergencies, Asthma
Question 21
An adult patient with a history of asthma presents to triage, stating that they are experiencing an acute asthma exacerbation. The emergency care provider orders an electrocardiogram (ECG). The patient asks the nurse why this procedure is necessary. What is the most appropriate response from the nurse?
“Respiratory complaints may be due to cardiac problems.”
✓
“ECGs can show us how well you are breathing.”
“It is a part of our order set for patients with respiratory complaints.”
“I don’t know. I just do what the provider orders.”
Correct Answer
“Respiratory complaints may be due to cardiac problems.”
A. Cardiac conditions, such as ST-elevation myocardial infarctions and dysrhythmias, can cause respiratory distress. Respiratory inefficacies can lead to myocardial irritation. All adult patients should have an ECG to rule out any coexisting cardiac conditions.
B. Telling the patient that an ECG is a standard of care can be reassuring, but it does not explain the reasoning as to why the procedure is necessary.
C. ECGs show the electrical activity of the heart and cannot indicate a patient’s respiratory effort.
D. This is never an acceptable answer for the professional nurse to provide to their patient. If the nurse does not understand why something has been ordered, they need to clarify the rationale with the provider. Patient education is a responsibility of the nurse throughout the patient’s care in the emergency department, not just at the time of discharge.
Category: Respiratory Emergencies, Asthma
Question 22
The nurse would expect arterial blood gas values from a patient in a severe chronic obstructive pulmonary disease exacerbation to illustrate what finding?
Metabolic acidosis
Metabolic alkalosis
Respiratory alkalosis
Respiratory acidosis
✓
Correct Answer
Respiratory acidosis
A. Damaged alveoli do not efficiently exchange oxygen and carbon dioxide (CO2). Retained CO2 lowers the overall pH of the blood, resulting in respiratory acidosis.
B. Respiratory alkalosis results from the presence of an increased blood pH and a decreased PaCO2 from a respiratory-related cause, such as hyperventilation.
C. This is seen in metabolic disturbances, such as diabetic ketoacidosis or tissue hypoxia, causing a lower pH level. Metabolic acidosis occurs because of a decrease in the kidneys’ ability to buffer the blood, resulting in a decrease in bicarbonate (HCO3) availability.
D. Metabolic alkalosis occurs from an increased pH that has a metabolic cause, such as a loss of gastric secretions from excessive vomiting.
Category: Respiratory Emergencies, Chronic obstructive pulmonary disease (COPD)
Question 23
A patient arrives via emergency medical services following a house fire. The patient has a Glasgow Coma Scale score of 15. What is the most appropriate method to assess current patency of the patient’s airway?
Count the respiratory rate
Ask the patient to state their name
✓
Visualize the oropharynx with a pen light
Obtain an oxygen saturation
Correct Answer
Ask the patient to state their name
A. Clear, audible speech indicates that there is no immediate threat to the patient’s airway. The presence of clear and audible speech is the easiest way to determine a patent airway when rapid assessments are needed. Signs of inhalation injury include hoarse voice, stridor, wheezing, cough, and presence of carbonaceous sputum.
B. Pulse oximetry only detects saturated hemoglobin and does not differentiate between oxygen and carbon monoxide hemoglobin saturation, so the pulse oximetry reading will usually appear to be within normal limits. A carboxyhemoglobin level will be necessary to determine the presence of carbon monoxide in the patient’s blood. Furthermore, this assessment does not evaluate the effectiveness of ventilation. It assesses oxygenation.
C. This assessment is crucial while obtaining vital signs, but it does not specifically tell the nurse about the patient’s airway patency.
D. Visualization may reveal edema to upper airways, but this view does not assess the entire airway.
Category: Respiratory Emergencies, Inhalation injuries
Question 24
A patient with severe respiratory distress has been intubated with an endotracheal tube (ETT), and mechanical ventilation has been initiated. The ventilator alarm is sounding, indicating high airway pressures. What should the nurse’s priority assessment be?
Auscultate bilateral breath sounds
Assess for airway secretions
✓
Check all connections on the ETT and ventilator
Assess the oxygen saturation
Correct Answer
Assess for airway secretions
A. The ETT can become occluded with secretions, resulting in an increase in pressure to deliver oxygen to the patient. The priority intervention is to assess for the need to suction the ETT and the patient’s airway. High-pressure alarms can be caused by coughing, gagging, secretions, ventilator asynchrony, kinked tubing, and tubing condensation.
B. Ventilator disconnection is a serious situation; however, the alarm typically associated with this event is a low airway pressure alarm.
C. Although assessing the oxygen saturation level is important to avoid the presence of hypoxemia, the first priority is to assess for airway clearance.
D. If, after suctioning the ETT, the ventilator continues to give high-pressure alarms, you should look for signs of pneumothorax (subcutaneous emphysema, absent/decreased breath sounds over the affected side, asymmetrical chest movement, tracheal deviation), but only after the airway has been assessed and cleared.
Category: Respiratory Emergencies, Obstruction
Question 25
A patient with a history of heart failure presents with complaints of difficulty breathing, presence of a nonproductive cough, and “stabbing” chest pain. On assessment, the nurse auscultates diminished breath sounds bilaterally. What additional information would be the most pertinent to obtain from the patient?
Recent sick contacts
Medication compliance
✓
Recent travel history
Vaccination history
Correct Answer
Medication compliance
A. Heart failure is one of the most common causes of pleural effusions. Cough, dyspnea, pleuritic chest pain, and decreased breath sounds are indicative of pleural effusions. It is important for the nurse to determine what medications the patient takes to treat their heart failure.
B. Sick contacts are assessed when patients report respiratory symptoms because many respiratory illnesses are viral or bacterial in nature. However, given the decreased breath sounds and the patient’s medical history, it is more relevant to collect additional information regarding the patient’s history of heart failure.
C. The nurse may assess if a patient has been vaccinated against diseases that cause respiratory symptoms, such as influenza and pneumonia. However, because heart failure seems to be the cause of the respiratory complaints in this scenario, it is most pertinent to assess management of the heart failure.
D. Recent travel is assessed because pulmonary embolisms caused by prolonged venous stasis may cause respiratory symptoms that mimic other respiratory conditions. However, because heart failure seems to be the cause of the respiratory complaints in this scenario, it is most pertinent to assess the management of heart failure.
Category: Respiratory Emergencies, Pleural effusion
Question 26
Which assessment finding would best indicate that chest tube insertion has been successful in relieving a tension pneumothorax?
Improvement in hemodynamics
✓
Bloody drainage in the chest tube
Immediate rush of air
Improved ability to deep breathe
Correct Answer
Improvement in hemodynamics
A. A tension pneumothorax is a life-threatening emergency that occurs when air enters the pleural space during inspiration and cannot escape during exhalation. The increasing intrathoracic pressure compresses the lungs, heart, and great vessels, resulting in markedly decreased cardiac output. Successful relief of a tension pneumothorax will be best assessed through the improvement of cardiac output via hemodynamics.
B. A rush of air may be heard after insertion of a chest tube or needle decompression; however, it is not the most reliable indicator of intervention success.
C. Bloody drainage may or may not be noted in the drainage chamber of the chest tube. This is not the most reliable indicator of success. Nursing assessment should focus on patient hemodynamics to evaluate the success.
D. Increased intrathoracic pressure causes bilateral lung collapse if left untreated, resulting in quickly progressing dyspnea and tachypnea. However, successful relief of a tension pneumothorax will be best assessed through the improvement of hemodynamics.
Category: Respiratory Emergencies, Pneumothorax
Question 27
A tube thoracostomy has been placed for a patient with a hemothorax. Immediately after placement, what output amount would alert the nurse to anticipate that the patient would be taken to the operating room for an emergency thoracotomy?
750 mL
1000 mL
✓
200 mL
500 mL
Correct Answer
1000 mL
A. If there is at least 1000 mL of blood in the chest initially or blood drainage greater than 200 mL per hour for 3–4 hours, then an emergency thoracotomy may be considered to identify and repair the bleeding source.
B. If there is at least 1000 mL of blood in the chest initially or blood drainage greater than 200 mL per hour for 3–4 hours, then an emergency thoracotomy may be considered to identify and repair the bleeding source.
C. If there is at least 1000 mL of blood in the chest initially or blood drainage greater than 200 mL per hour for 3–4 hours, then an emergency thoracotomy may be considered to identify and repair the bleeding source.
D. If there is at least 1000 mL of blood in the chest initially or blood drainage greater than 200 mL per hour for 3–4 hours, then an emergency thoracotomy may be considered to identify and repair the bleeding source.
Category: Respiratory Emergencies, Respiratory trauma
Question 28
A patient arrives complaining of a sudden onset of chest pain. The patient is anxious and tachypneic. Oxygen saturation is 89%. What is the priority intervention for this patient?
Initiate intravenous access
Obtain arterial blood gas
Obtain an echocardiogram
Administer supplemental oxygen
✓
Correct Answer
Administer supplemental oxygen
A. Ensuring adequate oxygen exchange through administration of supplemental oxygen is the priority intervention for this patient. An echocardiogram is an ultrasound diagnostic tool to determine the function and structure of the heart.
B. Although initiating intravenous access is an appropriate intervention, it is not the priority. Ensuring adequate oxygen exchange through administration of supplemental oxygen is the priority intervention for this patient.
C. Although obtaining arterial blood gas is an appropriate intervention, it is not the priority. Ensuring adequate oxygen exchange through administration of supplemental oxygen is the priority intervention for this patient.
D. Ensuring adequate oxygen supply through administration of supplemental oxygen is the priority intervention for this patient.
Category: Respiratory Emergencies, Pulmonary embolus
Question 29
Intravenous nicardipine (Cardene) has been ordered for blood pressure reduction in a patient with a hypertensive emergency. The patient’s blood pressure is 280/124 mm Hg with a mean arterial pressure (MAP) of 176 mm Hg. When titrating the nicardipine for this patient, which order has the safest parameter to follow?
Titrate nicardipine to a MAP of 124 mm Hg over the next hour
Titrate nicardipine to a MAP of 106 mm Hg over the next hour
Titrate nicardipine to a MAP of 132 mm Hg over the next hour
✓
Titrate nicardipine to a MAP of 158 mm Hg over the next hour
Correct Answer
Titrate nicardipine to a MAP of 132 mm Hg over the next hour
A. This is greater than the recommended 20–25% reduction of the MAP within the first hour of treatment and could result in organ hypoperfusion.
B. This is greater than the recommended 20–25% reduction of the MAP within the first hour of treatment and could result in organ hypoperfusion.
C. This is less than the recommended reduction of lowering the MAP by about 20–25% within the first hour for hypertensive emergency.
D. Hypertensive emergency is defined as severe hypertension with signs or symptoms of end organ dysfunction. It is recommended that the patient’s MAP be reduced by about 20–25% within the first hour of treatment, and rapid reduction of blood pressure should be avoided to prevent organ hypoperfusion.
Category: Cardiovascular Emergencies, Hypertension
Question 30
Which term is used to describe the form of shock that occurs following a large pulmonary embolism that results in unstable patient hemodynamics and decreased tissue perfusion?
Cardiogenic shock
Obstructive shock
✓
Distributive shock
Hypovolemic shock
Correct Answer
Obstructive shock
A. In obstructive shock, cardiac output and tissue perfusion are inadequate because of an obstruction limiting venous return to the heart during diastole. A large pulmonary embolism would create such an obstruction.
B. Distributive shock is caused by an abnormal distribution of intravascular volume and would not be caused by a pulmonary embolism.
C. Hypovolemic shock is caused by an insufficient amount of circulating blood and would not be caused by a pulmonary embolism.
D. Cardiogenic shock is the result of myocardial pump failure and would not be caused by a pulmonary embolism.
Category: Respiratory Emergencies, Pulmonary embolus
Question 31
What is the most appropriate initial treatment for acute respiratory distress syndrome (ARDS)?
Administer prophylactic antibiotics
Maintain adequate ventilation and oxygenation
✓
Maintain the patient in the supine position
Limit fluid intake to avoid risk of pulmonary edema
Correct Answer
Maintain adequate ventilation and oxygenation
A. The priority for the ARDS patient is strict focus on improving ventilation and oxygenation. Often this requires intubation and mechanical ventilation with expertise in various modes of ventilation.
B. Prone positioning has been particularly effective in the treatment of ARDS by exerting gravitational pull on the heart and mediastinum and allowing more alveolar recruitment.
C. Pulmonary edema is a component of ARDS; however, the most common extrapulmonary cause of ARDS is sepsis. Sepsis requires vigorous fluid administration as treatment.
D. Antibiotic treatment is controversial because of the risk of multi-drug-resistant infections. If pneumonia is identified as the cause, antibiotics are appropriate; however, oxygenation and ventilation take priority. If antibiotics are indicated, avoid medications that are nephrotoxic to avoid additional damage secondary to poor perfusion.
Category: Respiratory Emergencies, Respiratory distress syndrome
Question 32
A patient presents via private vehicle after a motorcycle crash involving a low-hanging tree limb. The patient complains of anterior neck pain. The nurse also notes a hoarseness in the patient’s voice and subcutaneous emphysema at the anterior inferior neck. What is the priority nursing action?
Apply a hard cervical collar
✓
Position the patient supine
Prepare for chest tube insertion
Prepare for a neck CT
Correct Answer
Apply a hard cervical collar
A. The patient is exhibiting signs and symptoms associated with laryngeal injury after a mechanism of action frequently associated with the disorder. The priority at this time is to maintain cervical immobilization because patients with laryngeal injury must be evaluated for concomitant cervical injury.
B. A CT is the cornerstone diagnostic test for this disorder; however, the priority is to maintain cervical spine immobilization.
C. Subcutaneous emphysema is associated with pneumothorax; however, in this scenario, the emphysema may be from the upper airway. Given the scenario, the priority is focused on preventing spinal cord trauma associated with possible cervical spine injury.
D. Semi-Fowler’s position is best for this patient. The patient should be given humidified air and kept NPO while maintaining vocal rest to minimize edema and subcutaneous emphysema.
Category: Respiratory Emergencies, Respiratory trauma
Question 33
A patient with a history of chronic obstructive pulmonary disease (COPD) presents with complaints of a runny nose, headache, and nonproductive cough for 3 days. The patient is able to speak without difficulty. Vitals signs are BP 158/88 mm Hg, HR 106 beats/minute, RR 22 breaths/minute, SpO2 88% room air, T 37.1°C (98.8°F). The priority intervention for the nurse to implement for this patient is which of the following?
Obtain a chest radiograph
Administer methylprednisolone
Apply low-flow supplemental oxygen
✓
Obtain an arterial blood gas analysis
Correct Answer
Apply low-flow supplemental oxygen
A. The patient’s oxygen saturation may be within the normal range for the individual; however, it is recommended that supplemental oxygen be provided to maintain oxygen saturation greater than 90%. The nurse should closely monitor the patient to avoid oxygen toxicity. Continuous oxygen saturation and end-tidal carbon dioxide monitoring is recommended.
B. Methylprednisolone may be indicated in the client presenting with a COPD exacerbation; however, the oxygen takes priority at this time.
C. Chest radiograph may help identify the specific cause of the patient’s symptoms, but oxygen takes priority.
D. Arterial blood gas measurements should be reserved for patients with moderate to severe exacerbations. Furthermore, oxygen is higher priority in this scenario.
Category: Respiratory Emergencies, Chronic obstructive pulmonary disease (COPD)
Question 34
A patient presents with an uncomplicated episode of migraine. The nurse has an order for diphenhydramine, ketorolac, and metoclopramide. The patient asks the reason for the diphenhydramine. What is the most appropriate response?
“The diphenhydramine works with the other medications to reduce your symptoms.”
“The diphenhydramine can help prevent side effects from another medication in the regimen.”
✓
“The diphenhydramine induces sleep to allow you to rest while your pain subsides.”
“The diphenhydramine reduces the chance of itching associated with the other medications.”
Correct Answer
“The diphenhydramine can help prevent side effects from another medication in the regimen.”
A. Diphenhydramine is administered because metoclopramide has a chance of causing dystonic reactions. Midazolam is another medication that can help prevent this complication.
B. This is not the best answer because the nurse has not provided an educated answer to the patient’s question. It is the responsibility of the nurse to understand and educate throughout the patient’s care.
C. The diphenhydramine may help the patient sleep, but that is not the primary intention for the medication.
D. The diphenhydramine does help with histamine response if one occurs as a result of the other medications; however, that is not the primary intention of the medication in this scenario.
Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)
Question 35
A 3-week-old infant presents with a temperature of 38.3°C (101.2°F). The caregivers report fever at home for a few days, with the child acting sleepier than usual. During the assessment, the nurse notes petechia to the anterior trunk and abnormal posturing with the head tilted posteriorly. What is the most appropriate diagnostic test to anticipate at this time?
Complete blood count
Lumbar puncture
✓
Chest x-ray
Urinalysis
Correct Answer
Lumbar puncture
A. Lumbar puncture (LP) is the diagnostic test to identify or rule out meningitis. Any infant younger than 2 months presenting with fever should be evaluated for meningitis. Given the high mortality associated with the disorder, it is crucial to identify the causative agent for the fever as soon as possible. Outcomes are improved when antibiotics are administered as soon as possible after the LP. Furthermore, the patient is exhibiting signs and symptoms of meningitis with fever, petechial rash, lethargy, and opisthotonos.
B. A chest x-ray may help diagnose pneumonia or other respiratory pathologies; however, given the infant’s presenting symptoms and immature immune system, the lumbar puncture must be performed to rule out meningitis.
C. A urinalysis may show a urinary tract infection; however, because of the high mortality associated with meningitis, it is crucial to identify or rule it out as soon as possible.
D. Complete blood counts often show elevated white blood cells in meningitis, but this diagnostic test is nonspecific.
Category: Neurological Emergencies, Meningitis
Question 36
A patient presents following a bar fight. The patient reports being punched in the face and having their neck forced backward. A few hours later, the patient began noticing upper extremity weakness with associated sensory loss. The patient also reports an inability to urinate, and the bladder scan reveals 300 mL of urine in their bladder. What is the most likely cause of the patient’s symptoms?
Central cord syndrome
✓
Anterior cord syndrome
Posterior cord syndrome
Brown–Séquard syndrome
Correct Answer
Central cord syndrome
A. Central cord syndrome results from a hyperextension injury of the cervical spinal cord. Common symptoms include upper and lower extremity weakness, with deficits more pronounced in the upper extremities. In addition, the patient may experience varying degrees of sensory loss, impaired pain, temperature, light touch, and position sense below the level of the injury. These symptoms do not typically involve bowel or bladder function but may lead to a neurogenic bladder. Symptoms are usually self-limiting.
B. Anterior cord syndrome is consistent with motor paralysis and a loss of pain and temperature sensation below the level of the injury, with a preservation of proprioception, touch, and vibratory sense. This syndrome results from a disruption of the anterior spinal artery.
C. Brown–Séquard syndrome is consistent with hemiparaplegia on the same side as the cord injury and hemianesthesia on the opposite side of the cord injury, but below the level of injury. It is typically related to penetrating injuries.
D. Posterior cord syndrome is consistent with hyperextension of the neck; however, light touch and proprioception are impaired but not completely lost. This disorder is rare.
Category: Neurological Emergencies, Head and spinal cord trauma
Question 37
A patient with a history of heart failure presents with dyspnea and pink frothy sputum. Crackles are noted bilaterally on auscultation. The patient is placed on bilevel positive airway pressure (BiPAP) at an inspiratory pressure of 10 cm H2O and an end-expiratory pressure of 5 cm H2O. What hemodynamic change is expected to occur as a result of noninvasive positive pressure ventilation (NIPPV)?
Increased afterload
Decreased cardiac output
Decreased preload
✓
Increased venous return
Correct Answer
Decreased preload
A. NIPPV decreases preload and blood flow into the right side of the heart (venous return).
B. NIPPV improves cardiac output by the reduction in preload and afterload.
C. NIPPV includes both continuous positive airway pressure (CPAP) and BiPAP devices. By increasing the pressure within the thoracic cavity through NIPPV, blood flow into the right side of the heart is reduced; this results in a decreased preload, which helps to improve pulmonary congestion in the acute heart failure patient.
D. Afterload is the pressure against which the heart has to pump when ejecting blood during systole. In heart failure, the left ventricle often has poor compliance and has difficulty in generating enough pressure to overcome the afterload and open the aortic valve so that blood moves forward. This can result in pulmonary edema. BiPAP can indirectly reduce the afterload by increasing the intrathoracic pressure, so the left ventricle does not have to work so hard to move blood forward.
Category: Cardiovascular Emergencies, Heart failure
Question 38
Which of the following statements indicates an understanding of discharge teaching post–carbon monoxide poisoning exposure?
“I can wait until next year to install a carbon monoxide detector.”
“I will return to the ED the next time I get a headache and feel tired.”
“I will only use an electric space heater indoors.”
✓
“I can continue to use the space heater even if I am not in the room.”
Correct Answer
“I will only use an electric space heater indoors.”
A. Carbon monoxide poisoning from faulty heaters or inadequate ventilation in the winter is the most frequent source of poisoning in the United States. A battery-powered carbon monoxide detector is recommended in all houses.
B. The use of space heaters powered by fuel rather than electricity in small, enclosed spaces can contribute to carbon monoxide poisoning.
C. Many severe cases of carbon monoxide poisoning are caused by faulty heating systems and poor ventilation. Space heaters should be turned off when no one is in the room.
D. Causes of headache can be numerous, and while it can accompany the presence of carbon monoxide poisoning, it is not the only symptom the patient will exhibit. Accompanying symptoms of carbon monoxide poisoning include loss of memory and concentration, personality changes, irritability, and extreme fatigue.
Category: Environment and Toxicology Emergencies, and Communicable Diseases, Toxicology, Carbon monoxide
Question 39
Which of the following is the priority intervention for a patient who presents with sudden onset of lip swelling, facial edema, and throat tightness and whose vital signs are BP 90/60 mm Hg, HR 127 beats/minute, RR 22 breaths/minute, T 38.6°C (97.8°F)?
High-flow oxygen
Epinephrine
✓
Aerosolized albuterol
Corticosteroids
Correct Answer
Epinephrine
A. The patient is experiencing an anaphylactic allergic reaction with evidence of angioedema. Epinephrine promotes peripheral vasoconstriction and bronchodilation and inhibits further release of mediators entering the bloodstream. The most common causes of an allergic reaction include the administration of antibiotics, bee or wasp stings, and exposure to peanuts.
B. Administration of high-flow oxygen to support oxygenation and treat hypoxia is important but will not act to reverse the signs and symptoms of anaphylaxis. It is important to treat the patient’s allergic reaction symptoms as quickly as possible to minimize the risk of complete airway compromise.
C. Corticosteroids are indicated to prevent a possible late biphasic reaction, yet there is no immediate effect in the treatment of an allergic reaction. Symptoms of an allergic reaction can occur quickly and progress rapidly, so prioritizing therapeutic interventions to administer rapid-acting medications is imperative.
D. Administration of albuterol will promote bronchodilation, thereby aiding in improving ventilation.
Category: Medical Emergencies, Allergic reactions and anaphylaxis
Question 40
A patient reports a red, itchy rash with blisters covering their face, neck, back, and arms. The rash appeared after hunting the previous day in a heavily wooded area. Which of the following medications does the nurse anticipate administering to this patient?
Oral antibiotic
Intravenous narcotic analgesic
Topical antifungal agent
Oral corticosteroid
✓
Correct Answer
Oral corticosteroid
A. The patient’s presentation is consistent with a diagnosis of poison ivy exposure. Because the rash is widespread, it is likely that an oral corticosteroid such a prednisone will be prescribed.
B. There are no signs of a bacterial infection at this time, so an antibiotic is not indicated.
C. An antifungal agent would not be the appropriate treatment for poison ivy exposure.
D. Narcotic pain medications are typically not prescribed in the treatment of poison ivy and may increase the itching the patient is experiencing. Acetaminophen or ibuprofen should be sufficient for the control of any discomfort.
Category: Medical Emergencies, Allergic reactions and anaphylaxis
Question 41
A patient is brought in after exhibiting aggressive behavior toward family members. To assess the patient’s current mental state, which question would be most important for the nurse to ask the patient?
“What past medical history do you have?”
“What brought this behavior on today?”
“What medications are you currently taking?”
“What are the voices telling you to do?”
✓
Correct Answer
“What are the voices telling you to do?”
A. Safety is the first priority for patients exhibiting aggressive or violent behavior. Establishing details of a patient’s thought process, such as the presence of auditory hallucinations, provides information about the current mental state and yields information into their suicidal or homicidal ideations.
B. Although determining the patient’s current medications is an important question, it does not provide information about the patient’s current mental state.
C. Past medical history is an important question to ask the patient because medical problems can result in psychiatric symptoms in some patients. It is more important, however, to quickly establish the patient’s current thought processes in relation to their current aggressive behavior.
D. Inquiring about precipitating events leading to the current behavior is important; however, the immediate safety of the patient and others is the highest priority.
Category: Mental Health Emergencies, Aggressive and violent behavior
Question 42
A patient with bipolar disorder has been receiving antipsychotic medications for the treatment of acute mania. Which diagnostic test should the nurse anticipate for this patient?
Complete blood count
12-lead electrocardiogram (ECG)
✓
Bladder scan
Liver function testing
Correct Answer
12-lead electrocardiogram (ECG)
A. Most antipsychotic medications can result in prolongation of the QT interval, which can lead to a life-threatening dysrhythmia. Performing a 12-lead ECG and initiating continuous ECG monitoring in a bipolar patient who is exhibiting acute mania is warranted.
B. Antipsychotic medications are not commonly associated with hepatic injury. Obtaining a 12-lead ECG and conducting continuous ECG monitoring is more important.
C. Though antipsychotic medications can cause urinary retention and other anticholinergic side effects, the potential cardiac effects are a higher priority.
D. Though clozapine (Clozaril), an atypical or second-generation antipsychotic, has the risk of causing neutropenia, this is not associated with all antipsychotics, and the potential cardiac effects are a higher priority.
Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 43
A patient arrives by emergency medical services after being found wandering on the street and talking loudly to themself. The patient will not answer to their name. Speech is clear, and the patient displays no signs of aggressive behavior, but will not make eye contact with the nurse or follow simple commands. Which of the following signs and symptoms would alert the emergency nurse to an organic cause for their psychosis?
Loud speech volume
Signs of trauma
✓
Tachycardia
Auditory hallucinations
Correct Answer
Signs of trauma
A. Any signs of trauma, especially head trauma, would require further investigation to determine whether the patient’s behavior has a psychiatric or an organic basis.
B. Abnormal vital signs indicating hypoxia or hypotension may indicate an organic cause of an altered mental response. Tachycardia alone is not specific to altered mental status.
C. Nonauditory hallucinations may be caused by hypoxia or hypoglycemia.
D. Loud speech volume alone does not correlate to an organic cause of psychosis, whereas impaired speech pattern may be a sign of an organic cause of a possible traumatic brain injury or a cerebral vascular incident.
Category: Mental Health Emergencies, Thought disorders (e.g., psychosis, schizophrenia)
Question 44
Ziprasidone (Geodon) is most appropriate for which of the following psychiatric scenarios? The adult patient who is:
having auditory hallucinations and is hearing that he should not move.
exhibiting acute depressive disorder and is tearful and sobbing.
exhibiting acute manic behavior, in handcuffs, and accompanied by police.
✓
experiencing extrapyramidal effects related to their psychiatric medications.
Correct Answer
exhibiting acute manic behavior, in handcuffs, and accompanied by police.
A. Antimanic drugs are not appropriate in the treatment of depression.
B. Ziprasidone is classified as an antimanic drug that has a rapid onset of action.
C. Auditory hallucinations, without evidence of mania, are not an indication for ziprasidone.
D. This patient would not benefit from receiving an antimanic drug. Extrapyramidal symptoms are treated with benztropine (Cogentin) or diphenhydramine (Benadryl).
Category: Mental Health Emergencies, Thought disorders (e.g., psychosis, schizophrenia)
Question 45
A patient presents voicing thoughts of suicidal ideation. Why is it important to identify and address medical issues before treating a mental health issue?
Mental health problems are not associated with serious medical illness.
Once in the ED, the patient is safe from suicide.
Medical problems can be resolved more quickly than behavioral problems.
Medical problems can mimic mental health problems.
✓
Correct Answer
Medical problems can mimic mental health problems.
A. It is important to rule out potential medical problems that may be life threatening and require immediate correction or patient stabilization. Medical problems can cause behavioral issues and can mimic mental health problems.
B. Mental health problems are true emergencies and may be caused by existing medical health problems.
C. Medical problems may be resolved quickly in some cases, but the reason for medical clearance is to rule out a medical cause for the mental health issue.
D. Patient safety must be ensured at all times during the ED visit. The patient remains at risk for suicide as long as they are having suicidal ideations.
Category: Mental Health Emergencies, Homicidal and suicidal ideation
Question 46
Which statement is correct regarding hemophilia disorders?
Two common triggers of hemophilia are hypoxia and dehydration.
Platelet administration is a common treatment in hemophilia.
There is an increased incidence of hemophilia in females.
Hemophilia is an inherited sex-linked genetic disorder.
✓
Correct Answer
Hemophilia is an inherited sex-linked genetic disorder.
A. Hemophilia is a sex-linked genetic disorder. Hemophilia A and B occur only rarely in females.
B. Treatment for hemophilia may include replacement of factor and administration of plasma or cryoprecipitate. Platelets are administered as part of the treatment for severe thrombocytopenia.
C. Hemophilia is an inherited sex-linked disease that alters factor production and function. The mother is the carrier and passes the trait on to her children. Active disease is most often expressed in males.
D. Hypoxia and dehydration are common triggers of sickle cell episodes. Complications from hemophilia are often seen with trauma and invasive procedures.
Category: Medical Emergencies, Hematologic disorders
Question 47
An elderly patient being evaluated following a fall is diagnosed with an intracranial bleed. The patient has been taking 300 mg of clopidogrel (Plavix) daily. What is the most appropriate action for the nurse to take?
Discontinue the clopidogrel immediately
✓
Administer vitamin K via intravenous route immediately
Decrease in the next dose of clopidogrel
Administer protamine sulfate via intravenous route immediately
Correct Answer
Discontinue the clopidogrel immediately
A. Vitamin K is the antidote for warfarin (Coumadin). There is no antidote for the presence of an excessive amount of clopidogrel in the bloodstream.
B. Protamine sulfate is the antidote for heparin. There is no antidote for the presence of an excessive amount of clopidogrel in the bloodstream.
C. Clopidogrel is an antiplatelet drug given as a 300 mg loading dose and then administered at 75 mg daily. The patient has been taking an excessive amount of the medication, resulting in the intracranial hemorrhage secondary to the fall. There is no chemical antidote or reversal agent for clopidogrel. The clopidogrel should be discontinued immediately.
D. The daily dose of clopidogrel is 75 mg, yet this patient has been taking 300 mg daily. The clopidogrel should be discontinued immediately. However, it can take up to 5 days for platelet aggregation to begin to occur following discontinuation of the medication.
Category: Medical Emergencies, Hematologic disorders
Question 48
A patient currently undergoing chemotherapy treatment for leukemia is being discharged following a facial laceration repair. Which statement best indicates to the nurse the patient’s understanding of the discharge instructions?
“I should return to the ED immediately for a temperature of 37.3°C (99.1°F).”
“Because I have a high white blood cell count, I am protected from getting an infection.”
“Pus will be expected during the healing because of my high white blood cell count.”
“I might not see the common signs of infection.”
✓
Correct Answer
“I might not see the common signs of infection.”
A. A temperature of 37.3°C (99.1°F) is not considered a fever. In most cases, fever is defined as a temperature of 38°C (100.4°F) or greater, in which case the patient should seek medical care.
B. Patients who are immune-compromised are generally neutropenic and are at great risk for infection. Because the body’s phagocytic response is impaired, the typical signs of infection, such as redness, swelling, or pus, may not be seen in this patient population.
C. Patients on chemotherapy have low white blood cell counts.
D. Pus is a product of phagocytosis. Patients on chemotherapy are generally neutropenic and may not experience phagocytosis even if they have an infection.
Category: Medical Emergencies, Hematologic disorders
Question 49
A 28-week-pregnant patient presents with right upper quadrant pain that is radiating to the right scapular area, beginning shortly after eating pizza. Based on the patient’s presentation, the most likely diagnosis is:
diverticulitis.
pancreatitis.
gastroenteritis.
cholecystitis.
✓
Correct Answer
cholecystitis.
A. Diverticulitis occurs when the diverticula become inflamed. Pain is persistent and localized to the left lower quadrant. It is commonly described as a “left-sided appendicitis.”
B. Symptoms of cholecystitis include a sudden onset of abdominal pain that is usually associated with ingestion of fatty or fried foods. Pain is located in the epigastrium and/or upper right quadrant. Pain may be referred to the right shoulder or supraclavicular area.
C. Pain with pancreatitis is generally located in left upper abdomen or epigastrium and may radiate through to the back.
D. Gastroenteritis is a common gastrointestinal illness that may have a viral or bacterial origin and may occur following ingestion of contaminated food. Symptoms would include nausea, vomiting, diarrhea, and abdominal cramps.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Cholecystitis
Question 50
A chronic alcoholic patient presents with a complaint of no alcohol for 2 days with nausea, vomiting, weakness, and restlessness. During the assessment, the emergency nurse notes hyperactive bowel sounds, orthostatic changes in their BP, and hematemesis. What is the priority intervention for the emergency nurse to perform?
Insert a large-diameter gastric tube.
Administer high-flow oxygen via nonrebreather mask.
Obtain a complete set of vital signs.
Establish IV access with two large-caliber catheters.
✓
Correct Answer
Establish IV access with two large-caliber catheters.
A. Gastric tube insertion should be done carefully to avoid inadvertent esophageal rupture. Insertion may be indicated, but the treatment of hypovolemia is the priority.
B. The evaluation of hemodynamic status through vital signs measurement is important in ongoing evaluation but is not a priority in light of the patient’s active bleeding.
C. Administering oxygen to this patient is an important intervention; however, the use of a nonrebreather mask would not be effective for a patient who is actively vomiting blood.
D. Therapeutic interventions should focus on the management of bleeding and hypovolemic shock.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Esophageal varices
Question 51
A child presents after choking on a plastic object. Their airway is clear, but the child has persistent drooling and difficulty swallowing. The nurse would anticipate what diagnostic procedure to be used to locate the foreign body?
End-tidal CO2 measurement
Direct laryngoscopy
Chest radiograph
✓
Bedside ultrasound
Correct Answer
Chest radiograph
A. Unless the object can be observed in the upper airway, a chest radiograph is best to determine the object’s location and to assist in determining the type of treatment necessary.
B. Ultrasound is a quick and accurate means to evaluate organ structure and identify vascular injuries. It is not a useful tool to evaluate the presence of a foreign body in the upper airway or gastrointestinal system.
C. The child’s respiratory status does not require endotracheal intubation, so an end-tidal carbon dioxide measurement would not provide any useful information.
D. Once the foreign body is located, direct laryngoscopy can be used to visualize and remove the foreign body, but a radiograph will initially define the existence and location of the object.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Foreign bodies
Question 52
A term newborn has been delivered in the emergency department. They have been warmed, temperature is being maintained, the airway is positioned, secretions have been cleared, and the baby has been dried and stimulated. To evaluate the effectiveness of these interventions, the nurse anticipates the infant’s targeted preductal oxygen saturation (SpO2) after 1 minute to be approximately:
63%.
✓
80%.
90%.
73%.
Correct Answer
63%.
A. According to neonatal resuscitation guidelines, the preductal oxygen saturation target 1 minute after birth should be in the range of 60–65%. After the baby’s initial cries and deep breaths, fluid moves out of the airways, causing the ductus arteriosus to constrict, and blood now flows from the right side of the heart into the lungs. It typically takes approximately 10 minutes for a normal full-term newborn to achieve oxygen saturation greater than 90%.
B. According to neonatal resuscitation guidelines, the preductal oxygen saturation target 3 minutes after birth should be in the range of 70–75%.
C. According to neonatal resuscitation guidelines, the preductal oxygen saturation target 5 minutes after birth should be in the range of 70–85 %.
D. According to neonatal resuscitation guidelines, the preductal oxygen saturation target 10 minutes after birth should be in the range of 85–95%.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Neonatal resuscitation
Question 53
A patient presents with complaints of malaise, fever, anorexia, and nausea for the past 2 weeks. The triage nurse becomes concerned that the patient may have developed hepatitis A when they report:
having recently traveled to Africa on a medical mission.
✓
having a history of intravenous (IV) drug use.
having sustained a tick bite while camping recently.
having unprotected sexual contact with an individual with HIV.
Correct Answer
having recently traveled to Africa on a medical mission.
A. In this case, it would be more likely that the patient might have contracted hepatitis B, which is transmitted principally by parenteral exposure but also can be transmitted through intimate contact. The highest rates of infection are among IV drug users and homosexual men.
B. Because hepatitis A is transmitted by the oral–fecal route, sharing used IV needles will not transmit the hepatitis A virus. The patient is at greater risk of contracting hepatitis B or human immunodeficiency virus from sharing used IV needles.
C. The bite of a tick may put the patient at risk for developing Lyme disease, but not hepatitis A.
D. The hepatitis A virus is transmitted by the oral–fecal route and is prevalent in areas of poor sanitation, which the patient may have encountered while working on the medical mission.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Hepatitis
Question 54
What is the most common cause of mechanical bowel obstruction?
Bacterial intestinal infection
Adhesions from previous surgeries
✓
Decreased blood supply to the intestines
Paralytic ileus
Correct Answer
Adhesions from previous surgeries
A. Paralytic ileus is a form of nonmechanical, not mechanical, obstruction.
B. Viral and bacterial infections can cause paralytic ileus, which is a nonmechanical obstruction.
C. The most common cause of mechanical obstruction is adhesions from previous abdominal surgeries.
D. Decreased blood supply to the intestines can cause paralytic ileus, which is a nonmechanical obstruction.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Obstructions
Question 55
A patient presents with complaints of pain and swelling in the right groin area. The patient states that the pain intensity has increased, and the swelling has become greater over the past 4–5 days. Which diagnostic test will best identify the source of the patient’s complaint?
Computed tomography (CT) scan of the abdomen
Abdominal radiograph
Magnetic resonance imaging of the abdomen
Abdominal ultrasound
✓
Correct Answer
Abdominal ultrasound
A. An abdominal radiograph would be helpful in diagnosing a bowel obstruction but would not provide enough information to validate a diagnosis of inguinal hernia. Plain films are usually indeterminate or nondiagnostic.
B. A CT scan of the abdomen would be helpful to identify the source of the patient’s discomfort in the absence of any physical signs. This patient has an obvious bulge in the inguinal area, so a CT scan would yield little additional information.
C. Magnetic resonance imaging might show the hernia, but the preferred method to diagnose a hernia is an ultrasound.
D. The patient’s symptoms are most likely a result of an inguinal hernia. The patient’s physical examination usually is diagnostic, but an ultrasound can be performed to determine if strangulation or an intestinal obstruction is present. Ultrasound has many advantages for diagnosis, but it is both operator and body habitus dependent. The primary role of ultrasound is the identification of the hernia itself.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Bowel perforation
Question 56
A 7-month-old is carried by a parent who notes that the infant has been irritable, crying loudly, and drawing up their legs at frequent intervals. You note that the child’s abdomen is distended and red mucus-like stool is in the diaper. The child’s symptoms are most consistent with which of the following conditions?
Appendicitis
Intussusception
✓
Incarcerated hernia
Pyloric stenosis
Correct Answer
Intussusception
A. Intussusception is the telescoping or prolapse of a segment of bowel into an adjacent segment, causing the classic symptoms of abdominal pain, a palpable abdominal mass, and “currant-jelly stools” with bloody mucus. It is more commonly seen in children between the ages of 3 months and 5 years. Sudden, acute, cramping pain and the child drawing up their legs are the most commonly reported signs. The child may be pain free between episodes.
B. Pyloric stenosis causes muscular thickening of the pylorus, leading to a functional gastric outlet syndrome. This disorder is the most common cause of intestinal obstruction in infancy. The infant typically presents with a previously normal feeding history and suddenly develops projectile emesis after eating. Occasionally an olive-shaped mass can be palpated in the right upper quadrant.
C. Acute appendicitis is one of the most common causes of abdominal pain. Classic symptoms include constant abdominal pain, fever, and vomiting. The pain may start as periumbilical and migrate to the right lower quadrant. Appendicitis occurs in all age groups but is rare in infants.
D. An incarcerated hernia typically presents as an asymptomatic bulge of a bowel loop that becomes more prominent with crying, laughing, or coughing. If circulation to the bowel loop is compromised, symptoms would include pain and swelling at the site of herniation, nausea and vomiting, and signs of a bowel obstruction. In children, these hernias are most commonly found in the inguinal area, where firm, tender masses can be palpated in the inguinal canal or scrotal area.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Intussusception
Question 57
A patient presents with sudden-onset severe epigastric pain following an alcohol binge. Pain is referred to his back and alleviated when he lies supine or leans forward. Physical examination reveals upper abdominal tenderness, tachycardia, and absent bowel sounds. What is the most likely disease process?
Cholecystitis
Bowel obstruction
Pancreatitis
✓
Pyelonephritis
Correct Answer
Pancreatitis
A. The pain associated with bowel obstruction is typically colicky, crampy, and intermittent. It is also poorly localized.
B. The pain associated with cholecystitis is typically felt in the right upper quadrant of the abdomen and may radiate to the right scapula or shoulder.
C. The pain associated with pyelonephritis originates in the flank or back at the costovertebral angle and may radiate to the groin.
D. The clinical hallmark of pancreatitis is abdominal pain in the epigastric area with radiation to the back. It can be relieved by eating, drinking, or leaning forward. Tachycardia may be noted as a result of third spacing.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Pancreatitis
Question 58
A motor vehicle collision victim presents with a seat belt injury to the abdomen. Vital signs are BP 100/72 mm Hg, HR 106 beats/minute, RR 18 breaths/minute, T 36.2°C (97.2°F). Which procedure would be anticipated to be performed as part of the patient’s initial assessment?
Focused assessment with sonography for trauma (FAST)
✓
Hemoglobin and hematocrit (H&H)
Computed tomography (CT) scan
Diagnostic peritoneal lavage (DPL)
Correct Answer
Focused assessment with sonography for trauma (FAST)
A. A CT scan should only be indicated for the hemodynamically stable patient. Although it is useful in determining the management of nonoperative solid organ injuries, a CT scan is not useful in identifying injuries to the diaphragm or gastrointestinal tract.
B. Hemoglobin and hematocrit will not reflect recent hemorrhage and should only be used as a baseline to compare future levels, especially if the patient needs surgery.
C. A FAST exam is a quick, accurate, and noninvasive bedside assessment tool that provides a rapid evaluation of the peritoneum and is recommended by the American College of Surgeons for the initial assessment of the patient with blunt abdominal trauma.
D. DPL is an invasive procedure reserved for the hemodynamically unstable patient. Vital signs for this patient do not suggest hemodynamic instability, so a FAST exam is appropriate.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Gastrointestinal trauma
Question 59
Raynaud’s disease is characterized by which assessment findings?
Intense vasospasms and pallor of the digits
✓
Severe leg cramps and redness
Carpopedal spasms and intense heat
Numbness and tingling of the wrist and elbow
Correct Answer
Intense vasospasms and pallor of the digits
A. Although leg cramps and redness may be associated with peripheral vascular disease, Raynaud’s disease typically affects the fingertips.
B. Carpopedal spasms may be caused by low blood calcium levels and have been associated with electrolyte disturbances connected to the presence of tetanus infections.
C. Raynaud’s disease affects blood vessels supplying the skin. Intense vasospasms are noted to the digits, tip of the nose, or ears. Because circulation is impaired, pallor is also noted, especially in cold environments. The disease affects women more than men and may also affect motor function.
D. Numbness and tingling are generally associated with the presence of a nerve injury.
Category: Cardiovascular Emergencies, Peripheral vascular disease
Question 60
Which of the following is the only proven medical therapy shown to reduce the progression and mortality of COPD?
Smoking cessation
✓
Short-acting inhaled bronchodilators
Pulmonary rehabilitation
Inhaled corticosteroids
Correct Answer
Smoking cessation
A. Studies have shown that the reduction of risk factors slows the progression of COPD. Eliminating cigarette smoking is the single most valuable therapy in the reduction of COPD.
B. Bronchodilators are used to control symptoms but have no effect on airway inflammation, which is a main cause of worsening disease.
C. Airway inflammation is a characteristic of COPD. Anti-inflammatory medications may decrease the frequency of exacerbations but have not been shown to improve lung function or decrease mortality.
D. Pulmonary rehabilitation can improve a patient’s quality of life by increasing exercise tolerance, but it does not improve lung function.
Category: Respiratory Emergencies, Chronic obstructive pulmonary disease (COPD)
Question 61
A patient presents as pale and diaphoretic with the following vital signs: BP 130/85 mm Hg, HR 135 beats/minute, RR 40 breaths/minute, SpO2 48% room air, T 37.2°C (99.0°F). Lung sounds are diminished bilaterally throughout, with crackles at the bases. The patient is visiting from Florida and has been in town for four days; the current elevation is 9500 feet. What condition should the nurse be most concerned about?
Pulmonary embolism
Pneumothorax
High-altitude pulmonary edema
✓
Pneumonia
Correct Answer
High-altitude pulmonary edema
A. The patient’s lung sounds are diminished bilaterally. This assessment finding is inconsistent with the presence of a pulmonary embolism. Findings consistent with pulmonary embolism include tachypnea, tachycardia, hypotension, and dyspnea.
B. Pneumonia is not associated with exposure to high altitude, and there is no recent history of a respiratory illness or fever.
C. The patient has bilateral lung sounds throughout the lung fields. A pneumothorax would result in the patient having absent or diminished breath sounds over the area of the pneumothorax.
D. The patient is visiting from another state with a near sea-level elevation. Current lung sounds reveal diminished lung sounds throughout, with crackles present at the bases. This assessment finding is concerning because of shifting of fluid into the lungs that is due to maladaptation to high-altitude exposure (9500 feet elevation).
Category: Respiratory Emergencies, Noncardiac pulmonary edema
Question 62
Which common healthcare issue affects the quality of life in patients with multiple sclerosis?
Depression
✓
Hypertension
Diabetes
Elevated cholesterol
Correct Answer
Depression
A. Hypertension may develop earlier in patients with multiple sclerosis, but the percentage of patients affected is no greater than in the general population.
B. As individuals with multiple sclerosis age, they have the same risk for comorbid conditions as the general population.
C. Depression is common among patients with multiple sclerosis, as with many chronic illnesses, and often goes undiagnosed.
D. As individuals with multiple sclerosis age, they have the same risk for comorbid conditions as the general population.
Category: Neurological Emergencies, Neurological disorders (e.g., multiple sclerosis, myasthenia gravis, Guillain–Barré syndrome)
Question 63
A patient has a 2-week history of repeatedly falling, accompanied by ascending weakness and tingling in the feet and fingers. There is loss of the knee-jerk reflex, and the patient is complaining of being unable to take a deep breath and of overall difficulty in breathing. Vital signs are BP 120/70 mm Hg, HR 72 beats/minute, RR 22 breaths/minute, SpO2 96% on room air. The emergency nurse suspects the patient may have which of the following?
Botulism
Guillain–Barré syndrome (GBS)
✓
Myasthenia gravis
Bell’s palsy
Correct Answer
Guillain–Barré syndrome (GBS)
A. Myasthenia gravis is caused by a defect in neuromuscular junction transmission of acetylcholine. Symptoms include ocular, facial, and neck weakness, as well as weakness of the upper extremities. The patient may demonstrate an abnormal smile, dysphagia, and the inability to manage their oral secretions, as well as difficulty speaking.
B. Guillain–Barré syndrome, also called acute inflammatory demyelinating polyneuropathy, is characterized by the rapid onset of numbness, weakness, and often paralysis of the legs, arms, breathing muscles, and face. Paralysis is ascending, meaning that it travels upward from the toes, upward along the lower extremities, and from fingers along the upper extremities toward the torso. Absence or loss of tendon reflexes is also evident as GBS progresses.
C. Bell’s palsy is a unilateral facial paralysis involving cranial nerve VII (facial nerve) that may result from the presence of herpes simplex virus within the facial nerve.
D. Botulism is caused by the Clostridium botulinum toxin. Botulism can be spread from home-canned or preserved food that has been improperly prepared. Symptoms include diplopia, blurred vision, drooping eyelids, muscle weakness, and dry mouth. Foodborne botulism usually begins 18–36 hours after consuming the contaminated food item.
Category: Neurological Emergencies, Neurological disorders (e.g., multiple sclerosis, myasthenia gravis, Guillain–Barré syndrome)
Question 64
A patient diagnosed with bacterial meningitis was given intravenous antibiotics and an antipyretic for fever. The nurse identifies that additional patient education is required for their diagnosis of bacterial meningitis when the patient states:
“I will take my antibiotics until my symptoms go away.”
✓
“I need to take medication to reduce my fever.”
“My girlfriend will need to be evaluated for this disease.”
“I will have to cancel my dinner plans with friends for this evening.”
Correct Answer
“I will take my antibiotics until my symptoms go away.”
A. Patients with meningeal disease are contagious, and chemoprophylaxis is required for anyone who is exposed directly to oral secretions of the infected individual.
B. Patients with meningeal disease are contagious and should limit their interactions with others until their symptoms are no longer evident.
C. Patients should take their fever-reducing medications until their fever is under control to minimize their discomfort and prevent further complications.
D. The patient’s symptoms are indicative of bacterial meningitis. Patients are contagious, requiring antibiotics and observation for potential complications.
Category: Neurological Emergencies, Meningitis
Question 65
A patient presents after two tonic–clonic seizure episodes within the previous 3 days despite being compliant with daily doses of levetiracetam (Keppra). Which of the following statements made by the patient indicates that additional education is required this medication?
“I limit alcohol to two drinks each night.”
✓
“I keep hydrated to protect my kidneys.”
“I use the rowing machine at the gym every day.”
“I use meditation to help with sleep.”
Correct Answer
“I limit alcohol to two drinks each night.”
A. Regular exercise contributes to overall health status and may assist with stress and coping with chronic illness. Activities chosen should consider the potential for injury should a seizure occur.
B. Regular sleep promotes general health, reduces stress on the system, and aids with coping.
C. Levetiracetam is excreted by the kidneys. Dehydration may cause concentration of medication, resulting in enhanced medication effects.
D. Drinking alcohol, even in small amounts, may trigger seizures. The central nervous system depressant effects of levetiracetam in combination with alcohol may enhance these effects, resulting in physical or mental impairment.
Category: Neurological Emergencies, Seizure disorders
Question 66
A patient presents via emergency medical services (EMS) with cervical spine precautions in place because of suspected spinal cord injury. Per the EMS report, the patient initially had bilateral wrist movement. On initial assessment, the nurse determines that the patient is now only able to shrug shoulders. The priority intervention for this patient would be to:
notify the trauma team.
✓
reassess patient function in 15 minutes.
document these new findings.
determine the patient’s pain level.
Correct Answer
notify the trauma team.
A. Movement of the wrists is a function of C6 and C7 innervation. Movement at only the shoulders would reveal a worsening condition with probable respiratory concerns because the shoulders are innervated at the level of C4/C5. This patient will require immediate diagnostic studies and treatment as deemed necessary by the trauma team.
B. Documentation is important. However, the priority would be to notify the trauma team for the appropriate treatment(s).
C. Determining the patient’s pain level is important. However, the priority would be to notify the trauma team.
D. This patient is not improving and has lost C6/C7 function. Immediate notification of the trauma team is indicated.
Category: Neurological Emergencies, Head and spinal cord trauma
Question 67
A patient weighing 100 kg will receive tissue plasminogen activator for an acute ischemic stroke. A dose of 100 mg is ordered, with 10% of the dose to be administered via intravenous push and the remaining dose to be administered over an hour infusion. After verifying the weight and dosing, it is determined that 0.9 mg/kg is the recommended dosing for acute ischemic stroke. What is the next action the nurse should perform?
Administer 9 mg over 1 minute, followed by the administration of 91 mg over 59 minutes via infusion pump.
Administer 10 mg over 1 minute, followed by the administration of 90 mg over 60 minutes via the infusion pump.
Administer 10 mg over 1 minute, followed by the administration of 90 mg over 59 minutes via infusion pump.
Notify the provider of the discrepancy between the order and the recommended dosing.
✓
Correct Answer
Notify the provider of the discrepancy between the order and the recommended dosing.
A. The maximum intravenous (IV) dose of tissue plasminogen activator (tPA) for ischemic stroke is 90 mg. The bolus is 10% of the recommended dose administered over 1 minute, and the remainder of the dose is given over 60 minutes via infusion pump.
B. The maximum IV dose of tPA for ischemic stroke is 90 mg. The bolus is 10% of the recommended dose administered over 1 minute, and the remainder of the dose is given over 60 minutes via infusion pump.
C. The maximum IV dose of tPA for ischemic stroke is 90 mg. The bolus is 10% of the recommended dose administered over 1 minute, and the remainder of the dose is given over 60 minutes via infusion pump.
D. The maximum IV dose of tPA for ischemic stroke is 90 mg. The bolus is 10% of the recommended dose administered over 1 minute, and the remainder of the dose is given over 60 minutes via infusion pump.
Category: Neurological Emergencies, Stroke
Question 68
The provider is considering the administration of alteplase (Activase/tPA) to an 82-year-old patient diagnosed with an acute ischemic stroke. In addition to the patient’s age, which other factor would exclude the patient from the administration of alteplase within the recommended extended 3- to 4.5-hour time window?
History of diabetes and previous stroke
✓
National Institutes of Health (NIH) Stroke Scale score greater than 20
Previous history of an ST-elevation myocardial infarction
NIH Stroke Scale score of 3
Correct Answer
History of diabetes and previous stroke
A. There is no upper limit within the NIH Stroke Scale for the administration of alteplase in the 3- to 4.5-hour time window.
B. There is no lower limit within the NIH Stroke Scale for the administration of alteplase.
C. A history of an ST-elevation myocardial infarction does not exclude the patient from receiving alteplase in the extended time window of 3 to 4.5 hours.
D. The exclusion criteria for the extended time window of 3 to 4.5 hours include both age greater than 80 years and a history of diabetes and prior stroke.
Category: Neurological Emergencies, Stroke
Question 69
Which of the following patient presentations would benefit from the administration of nimodipine (Nimotop) to decrease the risk of vasospasm and possible cerebral infarction?
Subarachnoid hemorrhage resulting from a cerebral aneurysm
✓
Subdural hematoma in a patient who abuses alcohol
Subdural hematoma in an elderly patient
Subarachnoid hemorrhage resulting from traumatic brain injury
Correct Answer
Subarachnoid hemorrhage resulting from a cerebral aneurysm
A. Nimodipine is a calcium channel blocker proved to improve outcomes in patients with nontraumatic subarachnoid hemorrhage by decreasing cerebral vasospasm and decreasing the incidence of cerebral infarction. This drug is not indicated, and shows no benefit, for traumatic subarachnoid hemorrhage or subdural hematoma, regardless of the cause.
B. Nimodipine is a calcium channel blocker proved to improve outcomes in patients with nontraumatic subarachnoid hemorrhage by decreasing cerebral vasospasm and decreasing the incidence of cerebral infarction. This drug is not indicated, and shows no benefit, for traumatic subarachnoid hemorrhage or subdural hematoma, regardless of the cause.
C. Nimodipine is a calcium channel blocker proved to improve outcomes in patients with nontraumatic subarachnoid hemorrhage by decreasing cerebral vasospasm and decreasing the incidence of cerebral infarction. This drug is not indicated, and shows no benefit, for traumatic subarachnoid hemorrhage or subdural hematoma, regardless of the cause.
D. Nimodipine is a calcium channel blocker proved to improve outcomes in patients with nontraumatic subarachnoid hemorrhage by decreasing cerebral vasospasm and decreasing the incidence of cerebral infarction. This drug is not indicated, and shows no benefit, for traumatic subarachnoid hemorrhage or subdural hematoma, regardless of the cause.
Category: Neurological Emergencies, Stroke
Question 70
Which type of skull fracture would place the patient at the highest risk for developing an intracranial infection?
Temporal bone fracture
Basilar skull fracture
✓
Depressed skull fracture
Linear skull fracture
Correct Answer
Basilar skull fracture
A. Basilar skull fractures include a fracture of any of the five bones at the base of the skull. These fractures can cause a laceration of the dura mater, resulting in an open passage of cerebrospinal fluid, which places the patient at risk for intracranial infections such as meningitis, encephalitis, and/or brain abscess. A linear skull fracture is a nondisplaced fracture of the cranium and does not increase the risk of intracranial infections. A depressed skull fracture is a fracture extending below the surface of the skull and lacerating the dura mater, which may cause intracranial infections; however, the incidence of infection is statistically higher in basilar skull fractures. Temporal bone fractures increase the risk of epidural hematoma.
B. A linear skull fracture is a nondisplaced fracture of the cranium and does not increase the risk of intracranial infections.
C. A depressed skull fracture is one that extends below the surface of the skull and can lacerate the dura mater, which may cause intracranial infections. However, the incidence of infection is statistically higher in basilar skull fractures.
D. Temporal bone fractures increase the risk of epidural hematoma.
Category: Neurological Emergencies, Neurogenic shock
Question 71
A patient presents with frequency and urgency of urination associated with right flank pain. On physical assessment, the patient exhibits a temperature of 38.8°C (102°F) and tenderness over the right costovertebral angle. Which of the following conditions is most consistent with this patient’s signs and symptoms?
Nephrolithiasis
Urethral stricture
Bladder infection
Pyelonephritis
✓
Correct Answer
Pyelonephritis
A. A bladder infection does have the symptoms of frequency, urgency, and burning on urination, but it is not usually associated with fever and tenderness over the costovertebral angle.
B. Although symptoms of nephrolithiasis can include urinary frequency and urgency, the cardinal sign is usually pain in the flank, abdomen, or groin area, depending on where the stone is located. This condition is not usually accompanied by fever.
C. Symptoms of pyelonephritis usually include pain on urination, frequency and urgency of urination, and flank or back pain on the affected side. Fever is one of the cardinal signs of pyelonephritis and can include the presence of chills. The costovertebral angle is located at the angle made by the vertebral column and the costal margin. When the affected side is percussed over the costovertebral angle, the patient with pyelonephritis will report pain.
D. Characteristic symptoms of urethral stricture are painful urination and urinary frequency and urgency. Additionally, the patient may experience a feeling of bladder fullness accompanied by the inability to urinate.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Genitourinary, Genitourinary infections
Question 72
The presence of a suspected testicular torsion is best evaluated using which of the following diagnostic studies?
Testicular transillumination
Computed tomography scan
Doppler sonography
✓
Urine culture and sensitivity
Correct Answer
Doppler sonography
A. The twisting of the testicle results in the strangulation of the blood supply to the testis. A computed tomography scan cannot determine adequacy of blood flow.
B. The diagnosis of testicular torsion is made by clinical findings and Doppler sonography, which will demonstrate a lack of blood flow to the affected testicle.
C. Testicular torsion most commonly results from a congenital abnormality of the testicle. Urinary tract infection is not the underlying cause.
D. Testicular transillumination is a useful diagnostic tool when a testicular mass is suspected.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Genitourinary, Genitourinary infections
Question 73
Following a motor vehicle collision, an unresponsive and intubated patient is received. On assessment, a rigid, bruised abdomen is noted, and a bedside ultrasound examination identifies a ruptured bladder. Based on this information, which of the following interventions is the priority action?
Prepare the patient for computed tomography scan
Administer intravenous antibiotics
Insert a urinary drainage catheter
Initiate intravenous fluid resuscitation
✓
Correct Answer
Initiate intravenous fluid resuscitation
A. The bladder has an extensive blood supply that is derived from the iliac artery, and bladder injuries resulting from a motor vehicle collision are most often associated with a pelvic fracture. For this reason, patients with a ruptured bladder are at risk for ineffective tissue perfusion and deficient fluid volume; therefore, intravenous fluid resuscitation is the priority intervention to avoid hypovolemia.
B. Accurate measuring of urinary output is crucial; however, initiating fluid resuscitation to avoid hypovolemia is the priority intervention.
C. A bedside ultrasound exam will detect fluid, including blood, in the abdomen. A computed tomography scan will most likely be required for further evaluation, but the results of the ultrasound provide sufficient information for the nurse to recognize that the patient is at risk for hypovolemia.
D. A patient with a ruptured bladder is at an increased risk for developing peritonitis, and antibiotics are indicated; however, the prevention of hypovolemia as a result of the injury is the priority intervention.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Genitourinary, Genitourinary trauma
Question 74
A 32-week-pregnant patient is involved in a motor vehicle collision. On arrival, the patient is complaining of severe abdominal pain. Blood is noted on the sheets around the patient’s lower extremities, and on assessment, the nurse determines the patient is bleeding vaginally. High-flow oxygen is administered via face mask. Which of the following would be the next intervention to perform?
Insert two large-caliber intravenous catheters
✓
Prepare the patient for a cesarean section
Initiate continuous fetal monitoring
Perform a type and cross-match
Correct Answer
Insert two large-caliber intravenous catheters
A. The patient likely has experienced a placental abruption as a result of the motor vehicle collision and requires insertion of two large-caliber intravenous catheters for the immediate administration of intravenous crystalloid fluid to prevent hypovolemia.
B. For patients with suspected placental abruption, a type and screen should be drawn and sent to the laboratory. However, in the case of emergent management, the emergency nurse should anticipate the need to administer type-specific or uncross-matched blood/blood products.
C. Fetal monitoring is important; however, initial interventions are directed toward maintaining the hemodynamic stability of the mother.
D. An emergency cesarean section may be necessary; however, maternal resuscitation is the priority at this time.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Abruptio placenta
Question 75
A patient diagnosed with a Chlamydia trachomatis vaginal infection should also be screened for which of the following associated sexually transmitted diseases?
Human papillomavirus (HPV)
Candidiasis
Bacterial vaginosis
Gonorrhea
✓
Correct Answer
Gonorrhea
A. HPV is the most common sexually transmitted disease in the world. Future problems with cancer can be a reality in both men and women.
B. Bacterial vaginosis is not a sexually transmitted disease; rather, it is caused by a disturbance in the normal vaginal flora.
C. Most cases of Candida infection are caused by the person’s own Candida organisms. Candida yeasts usually live in the mouth, gastrointestinal tract, and vagina without causing symptoms. However, when an imbalance occurs, such as when the normal acidity of the vagina changes or when hormonal balance changes, Candida can multiply and build up. When this occurs, the patient can experience signs and symptoms of candidiasis.
D. Gonorrhea is caused by the organism N. gonorrheae, a gram-negative organism. Coinfection with chlamydia and gonorrhea is common and the two infections should be treated concomitantly.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gynecology, Gynecological infections
Question 76
Which of the following statements made by a victim of sexual assault indicates the need for further education regarding the examination process on the part of the emergency nurse?
“I am so anxious, I don’t know how I will get through all of this.”
“I don’t feel comfortable with the policer officer in the room during my exam.”
✓
“Once the exam is finished, I’d like to take a shower.”
“I will need to be seen again in about one week to have more cultures taken.”
Correct Answer
“I don’t feel comfortable with the policer officer in the room during my exam.”
A. Following the examination and collection of evidence, the patient is allowed to shower, and clean clothing should be made available.
B. Being anxious is an expected response to the entire sexual assault experience. The patient may need emotional support, but more education about the actual process will probably not act to lessen the anxiety the patient is experiencing at this time.
C. Unless the patient requests an officer to be present during the examination, it is not done.
D. Sexually transmitted organisms such as chlamydia and gonorrhea that are transmitted during a sexual assault may not be present in sufficient quantity to yield a positive culture result at the time of initial examination. The patient should be instructed to obtain follow-up care within one week to obtain additional culture specimens. If the patient received prophylactic treatment, cultures should be obtained if the patient reports having symptoms.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gynecology, Sexual assault and battery
Question 77
A patient who is breastfeeding presents complaining of fever and right-sided breast redness and tenderness. In addition to antibiotic therapy, which of the following should be included in the discharge instructions for this patient?
Avoid hand-expressing or using a mechanical breast pump
Have the baby nurse from the unaffected breast only
Apply a warm compress to the breast before breastfeeding
✓
Stop breastfeeding, and supplement feedings with formula until the infection clears
Correct Answer
Apply a warm compress to the breast before breastfeeding
A. Emptying the breast is an important component in the management of mastitis. The use of a hand or mechanical pump is recommended, particularly if the infant is unable to effectively nurse.
B. Breastfeeding should be continued because treatment involves emptying the breast. Mastitis does not change the taste or nutritional value of breast milk.
C. Breastfeeding should be continued because treatment includes emptying the breast.
D. Warm compresses or a hot shower will help alleviate symptoms associated with mastitis and facilitate milk flow.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Postpartum infection
Question 78
A patient complains of fever and generalized abdominal pain with tenderness, and is hypotensive with tachycardia. They have a 2-year history of renal failure with nightly peritoneal dialysis. Which of the following would be the highest anticipated diagnosis?
Gastroenteritis
Bowel obstruction
Peritonitis
✓
Diverticulitis
Correct Answer
Peritonitis
A. Peritoneal dialysis can be a pathway to peritonitis. Symptoms that reflect this disease process include fever, generalized abdominal pain, tenderness, hypotension, and tachycardia. This is a serious problem for patients who have renal failure.
B. Gastroenteritis can present with symptoms of abdominal pain, but it is usually associated with nausea and vomiting and signs of dehydration. The patient in the scenario has a history of peritoneal dialysis, and this should lead the diagnostic plan toward peritonitis instead of gastroenteritis.
C. Diverticulitis can cause peritonitis but usually presents with left lower quadrant pain, along with nausea, vomiting, and fever. The peritoneal dialysis should move the practitioner toward peritonitis as the etiology.
D. Bowel obstructions will present with abdominal pain but will also be associated with distention, fever, nausea, vomiting, and constipation. The peritoneal dialysis should make the staff suspicious for peritonitis.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Peritonitis
Question 79
A 10-week-pregnant patient presents complaining of vaginal spotting with mild abdominal cramping and is discharged with a diagnosis of threatened abortion. Which of the following statements indicates a correct understanding of the discharge instructions?
“While I’m on bed rest, my partner and I can have sexual intercourse as long as it isn’t too rough.”
“I can expect the bleeding to get heavier in a day or two.”
“I will need to stay on bed rest for at least a day or two.”
✓
“I will keep a count of the number of tampons I use to determine how much I’m bleeding.”
Correct Answer
“I will need to stay on bed rest for at least a day or two.”
A. The patient should be instructed to count sanitary pads. Tampon use is discouraged in the presence of a threatened abortion.
B. A patient who is experiencing a threatened abortion will be instructed to maintain bed rest for 24–48 hours or until the bleeding stops.
C. An increase in the amount of bleeding or the passage of tissue may indicate the loss of the pregnancy, and the patient should immediately contact the obstetrician or return to the emergency department.
D. Sexual intercourse should be avoided as long as the bleeding and cramping continue and the patient is on bed rest. Intercourse can worsen cramping and bleeding or introduce infection if the cervical os begins to open.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Threatened/spontaneous abortion
Question 80
A patient presents with a thermal burn to the forearm. The burn is very painful and sensitive to air. The patient’s forearm area is red, involving the first few layers of the dermis, with a large fluid-filled blister. Which of the following would be the appropriate classification for this burn injury?
Fourth-degree burn
Full-thickness burn
Superficial burn
Superficial partial-thickness burn
✓
Correct Answer
Superficial partial-thickness burn
A. Only the epidermis is involved with superficial burns. The skin is red and painful. Superficial burns do not have blistering.
B. Fourth-degree burns involve underlying tissues, including muscles and tendons.
C. Superficial partial-thickness burns are very painful and involve only the first few layers of the dermis. Blistering is common with deep partial-thickness burns.
D. Full-thickness burns involve subcutaneous tissue and do not include blistering. These burns may be surrounded by deep partial-thickness or superficial partial-thickness burns.
Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Burns
Question 81
A patient presents with chest pain and diaphoresis, and denies dyspnea. Vital signs are BP 148/70 mm Hg, HR 72 beats/minute, RR 18 breaths/minute, SpO2 98% on room air. Breath sounds are clear and equal. The electrocardiogram shows an inferior wall ST-segment elevation. The nurse anticipates which order for oxygen?
No supplemental oxygen at this time
✓
Nonrebreather mask at 15 L per minute
Nasal cannula at 6 L per minute
Partial rebreather mask at 10 L per minute
Correct Answer
No supplemental oxygen at this time
A. The use of supplemental oxygen in normoxic patients has not been established. In patients with potential coronary artery syndrome, withholding of additional supplemental oxygen should be considered for those in the prehospital or inpatient hospital setting and the emergency department.
B. Supplemental oxygen has been shown to potentially extend the size of myocardial infarction in the setting of normoxia.
C. Supplemental oxygen in the setting of normoxia has not been shown to improve outcomes from myocardial infarction. The higher concentration of oxygen would not be indicated with an oxygen saturation of 98% on room air.
D. The use of supplemental oxygen in patients who are not hypoxic and are not exhibiting signs or symptoms of respiratory distress has not been shown to improve outcomes and may actually increase the size of the myocardial infarction.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 82
A patient complains of chest pain, dyspnea, and diaphoresis. Which of the following assessment factors would indicate a possible diagnosis of acute coronary syndrome?
Pleuritic chest pain
Positional chest pain
Chest pain that radiates to both shoulders
✓
Pain reproducible with chest wall palpation
Correct Answer
Chest pain that radiates to both shoulders
A. Pleuritic chest pain has a low likelihood of predicting acute coronary syndrome.
B. Positional chest pain has a low likelihood of predicting acute coronary syndrome.
C. Chest pain that radiates to both shoulders or pain that radiates to the right shoulder have a strong likelihood of predicting acute coronary syndrome (ACS), compared with pain that radiates only to the left shoulder.
D. Reproducible pain with palpation has a low likelihood of predicting acute coronary syndrome.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 83
A patient presents to the emergency department with abdominal pain and “ripping” back pain. Which condition places the patient at risk for abdominal aortic dissection?
Down syndrome
Ehler–Danlos syndrome
✓
Romano–Ward syndrome
Jervell and Lange-Nielsen syndrome
Correct Answer
Ehler–Danlos syndrome
A. Down syndrome is a chromosomal condition that causes learning difficulties. Patients with Down syndrome are at increased risk for heart defects, digestive problems, hearing loss, and sometimes hypothyroidism.
B. Romano–Ward syndrome is an inherited cardiac disorder that causes long QT syndrome. Patients with Romano–Ward syndrome may have sudden death resulting from a dysrhythmia.
C. Jervell and Lange-Nielsen syndrome is a condition that causes profound hearing loss from birth and also long QT syndrome. Patients with Jervell and Lange-Nielsen syndrome may have sudden death resulting from a dysrhythmia.
D. Patients with Ehler–Danlos syndrome may be identified by hypermobile joints and skin that is hyperextensible, has a soft, velvety-like appearance, is fragile, and tears or bruises easily. Ehler–Danlos syndrome is a connective tissue disorder that places patients at risk for the presence of aortic aneurysm and dissection.
Category: Cardiovascular Emergencies, Aneurysm and dissection
Question 84
A 7-year-old suddenly develops ventricular fibrillation. The child weighs 30 kg (66 lb). Cardiopulmonary resuscitation is started immediately. What is the correct defibrillation dose for the initial shock?
60 joules
✓
120 joules
30 joules
90 joules
Correct Answer
60 joules
A. The child weighs 30 kg. The correct initial joule dose is 2 joules per kg. The correct dose would be 60 joules for the initial shock, increasing to 4 joules per kg. This dose can be increased up to a maximum of 10 joules per kg.
B. This dose would be too low for the initial defibrillation of this child. The correct initial joule dose is 2 joules per kg.
C. This calculation would be using 4 joules per kg. This dose would be used for a second defibrillation attempt.
D. This calculation is not in accordance with the current pediatric advanced life support algorithm. The correct initial joule dose is 2 joules per kg.
Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 85
What electrocardiogram finding would a patient with a suspected tricyclic antidepressant overdose most likely have?
Ventricular fibrillation
Wide complex tachycardia with prolonged QT interval
✓
Sinus bradycardia
Narrow complex supraventricular tachycardia
Correct Answer
Wide complex tachycardia with prolonged QT interval
A. Cyclic antidepressants typically cause a tachycardia with prolonged QRS and QT intervals.
B. Although delayed or inappropriate intervention in the setting of cyclic antidepressant overdose may result in cardiopulmonary arrest and ventricular fibrillation, this is not the most likely dysrhythmia at this time.
C. Dysrhythmias from cyclic antidepressant toxicity typically are wide complex tachycardias.
D. Sinus tachycardia occurs frequently from the anticholinergic effects of tricyclic antidepressant toxicity. QRS complex widening occurs as a result of sodium channel blockade, and this delayed conduction may be seen more commonly involving the right side of the heart, manifesting as a right bundle branch block. In addition, QT interval prolongation can occur with these agents.
Category: Cardiovascular Emergencies, Dysrhythmias
Question 86
A patient has a pacemaker that only fires when the heart rate slows below a certain number of beats/minute. What pacemaker mode does the patient most likely have?
Magnet mode
Fixed-rate mode
Demand mode
✓
Asynchronous mode
Correct Answer
Demand mode
A. Asynchronous mode is another name for a fixed-rate pacemaker. A fixed-rate pacemaker will continue to deliver an impulse to “fire” regardless of the patient’s intrinsic heart rate.
B. Demand mode has the capability to sense the patient’s intrinsic heart rhythm and only delivers an impulse to “fire” when the patient’s intrinsic heart rate falls below a given rate.
C. Applying a magnet to a pacemaker will place it in magnet mode, which is an asynchronous or fixed-rate mode.
D. Fixed-rate mode delivers an electrical impulse at a given rate regardless of the patient’s intrinsic heart rate or rhythm.
Category: Cardiovascular Emergencies, Dysrhythmias
Question 87
A patient presents with a 24-hour history of abdominal pain, fever, nausea, and watery diarrhea. On further questioning, the patient states that they have been prescribed sulfamethoxazole/trimethoprim (Bactrim) for a urinary tract infection. What would your primary intervention be for this patient?
Place the patient in a private room on contact isolation
✓
Prepare to administer antibiotics
Request a stool sample from the patient
Prepare to infuse an isotonic crystalloid solution bolus
Correct Answer
Place the patient in a private room on contact isolation
A. Obtaining a stool sample to send for culture is common practice if the patient has had more than three diarrhea stools in 24 hours. However, these results take 48–96 hours, so the higher priority would be to isolate the patient.
B. Patients with known or suspected Clostridium difficile infections should be immediately placed on contact isolation to prevent spread to other patients and staff.
C. Clostridium difficile is a highly contagious bacterium that causes colitis in the large intestine. The bacteria may colonize or grow when a patient is on antibiotics, and normal intestinal flora are disrupted. Patients are capable of shedding the bacteria for several days after symptom resolution. The stool is highly contagious, and contact precautions should be implemented. A normal saline bolus may be indicated based on the patient’s hydration status. The higher priority would be to immediately isolate the patient.
D. Antibiotics are the standard treatment for Clostridium difficile; however, getting the patient to a private room and isolation would be a higher priority.
Category: Environment and Toxicology Emergencies, and Communicable Diseases, Communicable diseases, C. difficile
Question 88
Which of the following is considered an appropriate treatment for a patient with a venomous snake bite?
Contact poison control to have a specific antivenin prepared from the individual snake
Immobilize the involved area at or below above the level of the heart, and mark the leading edge
✓
Administer hepatitis B vaccine as soon as possible, and continue recommended dosing
Immediately apply ice packs and elevate the extremity
Correct Answer
Immobilize the involved area at or below above the level of the heart, and mark the leading edge
A. Providing immobilization and maintaining the extremity at the level or below the level of the heart is considered appropriate therapy following a venomous snake bite. Marking the leading edge for indication of progression is also recommended.
B. Updating tetanus vaccination, not hepatitis B vaccination, is recommended for the presence of venomous snake bites. Venomous snakes have not been proved to carry the hepatitis B virus.
C. Ice application can worsen patient outcomes following venomous snake bites because of tissue vasoconstriction. The extremity should be maintained at or below the level of the heart to minimize the risk of the snake venom entering the central circulation.
D. Universal antivenins are available in most emergency departments for common venomous pit viper snake bites. Bites from snakes not localized to the United States may require use of poison control. The antivenin should be administered as directed within 4 hours of the bite. Antivenin has been shown to be effective for up to 24 hours following envenomation.
Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Envenomation emergencies
Question 89
A potential sign commonly associated with the presence of cyanide poisoning is:
cherry-red skin.
severe respiratory distress.
✓
symmetrical descending muscular weakness.
excessive secretions.
Correct Answer
severe respiratory distress.
A. The appearance of cherry-red skin is more commonly associated with carbon monoxide poisoning. Patients will also exhibit headache, nausea, and shortness of breath.
B. Botulism results in the patient experiencing symmetrical descending muscular weakness. The patient may also experience blurred vision as a result of botulism.
C. Patients with organophosphate poisoning will experience excessive secretions, in addition to feelings of confusion. The patient may also experience crackles in bilateral lung fields.
D. Cyanide is a cellular asphyxiate and, at high doses, causes severe respiratory distress and kills very quickly. It interferes with cellular respiration and decreases use of oxygen, resulting in feelings of dizziness, bradycardia, and labored respirations. With excessive venous saturation, it may cause rose-colored skin.
Category: Environment and Toxicology Emergencies, and Communicable Diseases, Toxicology, Cyanide
Question 90
The key to safe and effective care of the trauma patient is which of the following?
Individual mental processes and individual leadership
Group diversity
Identified roles and responsibilities of the team members
✓
Engaging in individual member review of performance activities
Correct Answer
Identified roles and responsibilities of the team members
A. Clear and defined roles for each of the team members are a key component of the safe and effective delivery of trauma care.
B. The trauma team needs to be able to communicate effectively with one another to minimize errors and improve patient outcomes.
C. The trauma team needs one identified leader from whom all members of the team receive direction. This will lead to minimal errors, better team organization, and the development of clear goals.
D. A well-organized trauma team will conduct a review of the entire trauma resuscitation and critique how they can improve their communication for optimal patient outcomes.
Category: Professional Issues, Nurse, Evidence-based practice
Question 91
The child of a hospital employee has died in the emergency department. The staff and hospital employees are visibly upset and are having difficulty coping with the child’s death. As a result, the hospital administration decides to conduct a critical incident stress management (CISM) debriefing. Ideally, the CISM debriefing should take place within what time frame?
As soon as possible
Within 24–72 hours
✓
Within 3–5 days
Within 1 week
Correct Answer
Within 24–72 hours
A. The emergency department nurse manager will be unable to schedule a CISM debriefing immediately following the incident. The social work department, CISM team, and chaplain will schedule the formal debriefing within 1–3 days.
B. A formal debriefing should be scheduled within 24–72 hours (1–3 days) of the incident to allow the involved staff to debrief and to openly discuss their feelings.
C. The sooner involved staff members are able to discuss their feelings, the sooner they can begin their grieving and healing process to cope with the events of the incident.
D. If the CISM debriefing takes place after more than 72 hours have passed, those involved may have forgotten key elements they wish to discuss surrounding the event. This delay can actually cause staff members to be unable to understand their feelings surrounding the event. Staff members may be unable to return to work in a timely fashion because of their continued stress relating to the event.
Category: Professional Issues, Nurse, Stress management (e.g., burnout, compassion fatigue, PTSD)
Question 92
The nurse is aware that lifelong learning is an essential career element that leads to the achievement of which of the following?
Professional expertise
✓
Personal fulfillment
Academic success
Promotion to a management position
Correct Answer
Professional expertise
A. As evidenced in the nursing theory text From Novice to Expert by Patricia Benner, participation in lifelong learning is an essential element in the transition from a novice to an expert professional.
B. Depending on the specific qualifications of the management position, a program of lifelong learning may or may not be a requirement.
C. Lifelong learning can contribute to academic success; however, lifelong learning often occurs outside the classroom with coaches or mentors who have no direct relation to an academic program.
D. Lifelong learning may contribute to a nurse’s personal fulfillment, but it is an essential component in the transition from novice to expert.
Category: Professional Issues, Nurse, Lifelong learning
Question 93
Accurate documentation of the “chain of custody” in the handling of forensic evidence is necessary to ensure which of the following?
Limiting the number of individuals who handle the evidence
Providing law enforcement with evidence needed to convict the suspected criminal
Safeguarding the integrity of the evidence
✓
Validating the competency of the individual who collected the evidence
Correct Answer
Safeguarding the integrity of the evidence
A. Documentation of a chain of custody does not validate the competence of the evidence collector; it only provides a detailed account of when the evidence was collected, secured, and properly transferred without interference, potential contamination, or loss.
B. Accurate documentation of the chain of custody when handling forensic evidence establishes the integrity of the evidence and ensures that it was not subjected to contamination or tampering.
C. Emergency nurses do not collect evidence to show proof that a crime was committed. The chain of custody validates the authenticity of the evidence so that it can be accepted in a court proceeding.
D. The best practice in forensic evidence collection is to limit the number of individuals who handle the evidence. However, the chain of custody documentation only identifies the individuals who handled the evidence; it does not limit the number.
Category: Professional Issues, Patient, Forensic evidence collection
Question 94
The nurse is aware that the most reliable method of assessing a patient’s pain is which of the following?
Asking the patient to describe what pain-relieving medications have been effective for them in the past
Observing specific pain-associated behaviors, such as grimacing or crying
Acknowledging the patient’s self-report of pain
✓
Using a nurse-initiated pain management protocol
Correct Answer
Acknowledging the patient’s self-report of pain
A. Nurse-initiated pain management protocols can shorten the time that the patient must wait before receiving pain medication. However, the protocol is a nursing intervention that must be based on an accurate pain assessment.
B. The behaviors and attitudes exhibited by an individual who is experiencing pain (i.e., stoicism versus emotive) may be driven by familial, ethnic, or cultural norms; therefore, observing specific behaviors is not a valid means of measuring an individual’s level of pain.
C. The pain experienced by the patient may not be related to the current pain experience. Pain medication is an intervention that must be based on an accurate and valid assessment of the patient’s current level of pain.
D. The most reliable means of assessing a patient’s pain is based on the patient’s self-report of pain. The various pain scales available provide the patient with a tool that can objectively measure the intensity of the pain experience.
Category: Professional Issues, Patient, Pain management and procedural sedation
Question 95
A 5-year-old patient presents to the hospital and requires a dose of oral medication for the illness. The nurse understands that this patient is at increased risk for medication errors because of the following:
Patient having no known allergies
Inability to swallow medications
Weight-based dosing
✓
Parent being a poor historian
Correct Answer
Weight-based dosing
A. A patient’s inability to swallow is of concern, and precautions or a change in the route of administration should be considered. However, the primary cause for medication errors in children is the failure to administer medications per weight-based dosing.
B. A parent who is unable to provide an adequate health history is not the primary cause for medication errors in children. For mediations to be administered in the appropriate dose, the child’s weight must be obtained and the medication dose properly calculated.
C. It is important to be aware of any drug allergies a patient may have before the administration of medication. However, for mediations to be administered in the appropriate dose, the child’s weight must be obtained and the medication dose properly calculated.
D. Children pose a risk for emergency care because most emergency departments are built around adult needs. Children are at increased risk of medication errors because of weight-based dosing, medicine dilution, and the inability to communicate their needs or responses.
Category: Professional Issues, Patient, Patient safety
Question 96
A patient with an acute myocardial infarction is being prepared for transport by emergency medical services (EMS) to the nearby medical center. The patient is stable but is receiving multiple intravenous vasoactive medications. The nurse should be most concerned with which of the following?
The patient’s spouse is insisting that they ride along in the ambulance.
The patient is being transferred via ground ambulance rather than helicopter.
The patient experiences motion sickness when flying or riding in a vehicle.
The transport team comprises individuals with training in basic life support.
✓
Correct Answer
The transport team comprises individuals with training in basic life support.
A. It is understandable that a family member would want to ride along in the ambulance, and their presence can be comforting for the patient, especially a child, but the practice is not always wise or possible. Transport companies have specific policies regarding family members accompanying patients in the ambulance.
B. Although it is desirable to transport this patient as quickly as possible, factors such as weather and patient size and weight may influence the choice of vehicle for patient transport. The Emergency Medical Treatment and Active Labor Act requires only that a transfer be carried out by qualified personnel using equipment required by the patient’s condition.
C. Members of the transport team must have the necessary knowledge and skills to care for the patient. The management of intravenous vasoactive medication is beyond the scope of a basic life support provider. The nurse should not allow the transport to proceed until an advanced life support provider is available to accompany the patient.
D. The patient who experiences motion sickness should be prophylactically premedicated to prevent nausea and vomiting. Motion sickness is not a reason to abort or delay the transfer.
Category: Professional Issues, Patient, Transfer and stabilization
Question 97
A non-English-speaking patient presents to the triage nurse. The best method for the triage nurse to effectively communicate with the patient is to use which of the following?
A member of the patient’s family or a friend
A member of the healthcare staff who speaks the patient’s native language
A certified translator fluent in the patient’s native language
✓
An illustrated chart for the patient to point at descriptors of the symptoms
Correct Answer
A certified translator fluent in the patient’s native language
A. Fluency in a language does not guarantee that an individual is a qualified interpreter. A certified interpreter or designated interpretation service is a better alternative.
B. Using a family member or friend of the patient to provide interpretive services would be a violation of the patient’s right to privacy.
C. The use of an illustrated chart may be helpful in some situations; however, use of the illustrations alone does not comply with Title VI of the Civil Rights Act.
D. Title VI of the Civil Rights Act requires interpreter services for all patients with limited English proficiency. The patient must be afforded the ability to ask questions and understand the answers to their questions and participate in their plan of care. A certified interpreter or language interpretation service should be used.
Category: Professional Issues, Patient, Cultural considerations (e.g., interpretive services, privacy, decision making)
Question 98
The nurse caring for a geriatric patient delegates hourly vital signs to unlicensed assistive personnel (UAP). The UAP staff does not report a hypotensive blood pressure to the nurse and only documents it on the patient’s chart. As a result, the patient suffers a poor outcome. Who is at fault for not reporting the hypotensive blood pressure to the physician?
The patient’s primary care provider
The charge nurse on the unit
The assistive staff member who took the patient’s vital signs
The nurse who delegated the task of vital signs
✓
Correct Answer
The nurse who delegated the task of vital signs
A. The nurse holds the unlicensed assistive personnel responsible for the completion of the delegated task and for reporting any changes in the patient’s condition. However, the RN is responsible for the delegation decision, the process, and the ongoing monitoring of the outcomes of the patient’s nursing care.
B. The nurse holds the unlicensed assistive personnel responsible for the completion of the delegated task and for reporting any changes in the patient’s condition. However, the nurse is accountable for the delegation decision, the process, and the ongoing monitoring of the outcomes of the patient’s nursing care.
C. The nurse holds the unlicensed assistive personnel responsible for the completion of the delegated task and for reporting any changes in the patient’s condition. However, the nurse is accountable for the delegation decision, the process, and the ongoing monitoring of the outcomes of the patient’s nursing care.
D. The nurse holds the unlicensed assistive personnel responsible for the completion of the delegated task and for reporting any changes in the patient’s condition. However, the nurse is accountable for the delegation decision, the process, and the ongoing monitoring of the outcomes of the patient’s nursing care.
Category: Professional Issues, System, Delegation of tasks to assistive personnel
Question 99
Using the mass casualty START triage system for adults, which of the following patients would be classified as a yellow (delayed) patient?
A patient who is able to stand and walk to a designated area as instructed
✓
A patient who is unable to ambulate, has no spontaneous respirations even with repositioning of the airway, has an absent central pulse, and does not follow commands
A patient who is unable to ambulate, with a respiratory rate of 32 breaths/minute
A patient who is unable to ambulate and who can follow commands, with a respiratory rate under 30 breaths/minute
Correct Answer
A patient who is able to stand and walk to a designated area as instructed
A. Patients who are able to ambulate unassisted and walk to a designated area are classified as “walking wounded,” or the green simple triage and rapid treatment (START) triage category.
B. This patient is classified as red in the START triage category because of a respiratory rate over 30 breaths/minute and being unable to ambulate.
C. Patients who do not have spontaneous respirations after repositioning of their airway are classified as black (expectant). Additional classification criteria do not matter because this patient is not breathing and is considered expectant; attempting resuscitative measures in a mass casualty incident would require more resources than are potentially available.
D. Patients who are unable to ambulate but meet the START triage criteria of respiratory rate less than 30 breaths/minute, capillary refill of less than 2 seconds, and ability to follow commands fall into the yellow START triage category.
Category: Professional Issues, System, Disaster management
Question 100
The National Incident Management System requires that hospitals have plans and procedures in place to be prepared for emergency management situations, such as mass casualty incidents and disasters. Which system helps hospitals create a command structure to be better prepared for these incidents?
Hospital Incident Command System (HICS)
✓
Disaster Medical Assistance Team (DMAT)
Federal Emergency Management Agency (FEMA)
National Response Framework
Correct Answer
Hospital Incident Command System (HICS)
A. FEMA is one of the federal agencies that trains and assists the country during disasters. FEMA may be involved in disaster management at the hospital level, depending on the size of the event. However, HICS is the system that is specific to hospital command in a disaster or mass casualty incident.
B. The National Response Framework is a plan for how the United States as a nation responds to disasters. This response can be from the local level all the way up to the national level for disasters that require federal support. HICS is the hospital command structure that is used within hospitals to plan, prepare, and implement a command structure for disasters and mass casualty incidents.
C. HICS is a National Incident Management System approved for hospitals to use in their response to mass casualty incidents and disaster management. HICS provides a command structure for hospitals with specific job functions under each command level to assist a hospital in managing emergency response situations.
D. A DMAT is a trained medical team that responds to disasters when needed. Although a DMAT may assist a hospital when a mass casualty event or disaster happens, it is not a system used by hospitals to respond in a disaster. HICS is used within hospitals to plan, prepare, and implement a command structure for disasters and mass casualty incidents.
Category: Professional Issues, System, Disaster management
Question 101
To be compliant with the U.S. Emergency Medical Treatment and Active Labor Act, all patients presenting to the emergency department must have had which of the following performed?
Triage assessment by a registered nurse
At least one set of vital signs
Medical screening exam (MSE)
✓
Emergency Severity Index acuity level assigned
Correct Answer
Medical screening exam (MSE)
A. An MSE performed by a qualified person as identified by the hospital bylaws is required by law. This can be a physician, advanced practice provider, or a labor and delivery nurse. Triage does not fulfill the legal requirement of the patient receiving an MSE.
B. An MSE performed by a qualified person as identified by the hospital bylaws is required by law. This can be a physician, advanced practice provider, or a labor and delivery nurse. Assigning an Emergency Severity Index acuity level is not equivalent to performing an MSE and does not fulfill the legal requirement of the patient receiving an MSE.
C. An MSE is performed by a qualified person as identified by the hospital bylaws. This can be a physician, advanced practice provider, or a labor and delivery nurse.
D. An MSE performed by a qualified person as identified by the hospital bylaws is required by law. This can be a physician, advanced practice provider, or a labor and delivery nurse. One set of vital signs would be a component of an MSE but does not entail the complete MSE process.
Category: Professional Issues, System, Federal regulations (e.g., HIPAA, EMTALA)
Question 102
An unresponsive trauma patient is brought in by ambulance. No family members are present, and no contact information is available for the patient’s family. It is appropriate for hospital personnel to treat this patient based on which type of consent?
Involuntary consent
Expressed consent
Implied consent
✓
Informed consent
Correct Answer
Implied consent
A. When a patient is unconscious or unable to provide verbal consent, no family members are present to provide consent for treatment, and immediate interventions are necessary to save the patient’s life and/or limb, the physician is obligated to act on the patient’s behalf. The action is referred to as implied consent.
B. If a patient is alert and oriented, they can provide expressed consent. Expressed consent occurs when a patient voluntarily consents to medical treatment and is predicated on the patient’s mental capacity. Because the patient is unresponsive and in a life-threatening situation, treatment for this patient is based on implied consent.
C. Involuntary consent is indicated when an incompetent individual refuses necessary medical treatment, and they require immediate intervention to save life or limb.
D. Provided by the physician, informed consent describes the procedure being performed, the alternatives to the procedure, and the risks and benefits associated with the procedure. Informed consent is based on the patient’s understanding of the risks, benefits, and alternatives to any therapy or procedures. Because the patient is unresponsive, they cannot be provided with the description, alternatives, risks, and benefits of any therapy or procedures.
Category: Professional Issues, System, Patient consent for treatment
Question 103
According to The Joint Commission, the overwhelming majority of serious medical errors that occur during patient handoff can be attributed to which type of mechanism?
Inappropriate staffing mix at the receiving facility
Equipment failure
Use of unapproved abbreviations
Communication breakdown
✓
Correct Answer
Communication breakdown
A. Equipment failure, especially when it involves a monitoring device, can impact patient safety during medication administration, but it is usually not a concern at the time of patient handoff/transfer.
B. Communication at the time of patient handoff/transfer should occur between caregivers of equal or higher level of knowledge, skill, and critical thinking ability, so the staffing mix at the time of transfer would not be relevant.
C. The Joint Commission requires accredited organizations to use a standardized approach to handoff communications, citing research suggesting that approximately 80% of serious medical errors occur because of miscommunication during patient handoffs/transfers.
D. The use of unapproved abbreviations contributes to medication errors. However, their use is only part of the communication process that takes place at the time of patient handoff/transfer.
Category: Professional Issues, System, Risk management
Question 104
A patient who recently returned from a trip to East Africa presents to triage complaining of fever, abdominal pain, bloody diarrhea, and weakness. The nurse recognizes that this patient is most at risk for which of the following?
Ebola virus
✓
Chickenpox
Influenza
Gastroenteritis
Correct Answer
Ebola virus
A. Fever, abdominal pain, weakness, muscle pain, diarrhea, fatigue, vomiting, and unexplained hemorrhage and bruising with known recent travel to East Africa put this patient most at risk for having the Ebola virus.
B. Chickenpox presents with a vesicular rash, fever, loss of appetite, fatigue, and headache. Recent travel to Africa would be less likely to result in contracting chickenpox as compared with contracting the Ebola virus.
C. Diarrhea, vomiting, abdominal pain, fever, and fatigue are all signs and symptoms of gastroenteritis. Gastroenteritis is contagious and caused by a virus, but with the patient’s recent travel to Africa and the unexplained bleeding and bruising, the nurse should be more concerned that the patient may have contracted the Ebola virus.
D. Influenza is another viral illness, but patients will typically present with fever, cough, sore throat, runny nose, muscle or body aches, fatigue, and headache. The recent travel to Africa and unexplained bleeding should cause the nurse to be more concerned regarding the possibility of the Ebola virus rather than the presence of influenza.
Category: Professional Issues, System, Symptom surveillance (e.g., mandatory reporting of diseases, symptom clusters)
Question 105
Which of the following is an early sign of impending shock during the initial assessment of an adult patient?
Systolic blood pressure greater than 90 mm Hg
Temperature of 37°C (98.6°F)
Capillary refill less than 2 seconds
Respiratory rate greater than 22 breaths/minute
✓
Correct Answer
Respiratory rate greater than 22 breaths/minute
A. Tachypnea is a common finding and occurs in an effort to decrease carbon dioxide and compensate for cellular acidosis. Gradual increases in depth and rate of respiration may be early signs of impending shock. Breath sounds may also be absent, unequal, or diminished.
B. Systolic blood pressure less than 90 mm Hg is considered a subtle sign of shock.
C. Temperature > 38.3°C (100.94°F) or < 36°C (96.8°F) may be a subtle sign of septic shock.
D. Capillary refill greater than 2 seconds may be a subtle sign of shock in the adult patient.
Category: Medical Emergencies, Hypovolemic and distributive shock
Question 106
The four classifications of radiation particles that can affect life are alpha particles, beta particles, gamma radiation, and neutrons. Of these four, which can penetrate the most objects (paper, wood, concrete) and is therefore more dangerous to life?
Gamma radiation
Alpha particles
Neutrons
✓
Beta particles
Correct Answer
Neutrons
A. Gamma radiation can be absorbed by paper and wood but cannot be absorbed by concrete.
B. Beta particles can only be absorbed by paper, not by wood or concrete. These radioactive particles can produce long-term health effects depending on the degree of exposure.
C. Neutrons can be absorbed by all three objects—paper, wood, and concrete—and are therefore more dangerous to life.
D. Alpha particles cannot be absorbed by paper, wood, or concrete. However, these radioactive particles can have long-term health effects based on the amount of exposure.
Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Temperature-related emergencies
Question 107
A child is brought to the emergency department after falling through the ice while skating on a lake. On arrival, the patient’s core temperature is 26.8°C (80.2°F). The nurse would anticipate this patient to exhibit which signs or symptoms?
An increased respiratory rate and effort
Unresponsive, not shivering but with vital signs
✓
An increased urinary output
Slow or slurred speech
Correct Answer
Unresponsive, not shivering but with vital signs
A. The basal metabolic rate decreases by 2–3 times the normal rate in the hypothermic patient. The most evident response is seen in the central nervous system. With a body temperature of 26.8°C, the child will be unresponsive.
B. In the hypothermic patient, decreased respiratory rate and effort are expected. This can lead to carbon dioxide retention, hypoxia, and acidosis.
C. Renal blood flow decreases, and the glomerular filtration rate declines in the hypothermic patient. Therefore, a decrease in urine output would be expected.
D. Metabolism in the liver slows, so medications may last longer in the hypothermic patient. Therefore, an increased medication effect would be expected.
Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Temperature-related emergencies
Question 108
Which of the following patients should receive rabies prophylaxis?
The patient with a bite from a pet cat
The patient with a bite from a pet dog
The patient who may or may not have been bitten by a guinea pig
The patient who may or may not have been bitten by a bat in the house
✓
Correct Answer
The patient who may or may not have been bitten by a bat in the house
A. Domestic cats are usually vaccinated against rabies. Bites from any animal that can be observed for 2 weeks, such as pets or other domesticated animals, usually do not require rabies prophylaxis.
B. Domestic dogs are usually vaccinated against rabies. Bites from any animal that can be observed for 2 weeks, such as pets or other domesticated animals, usually do not require rabies prophylaxis.
C. Bats are a common carrier of rabies. Rabies prophylaxis is recommended when someone has been either exposed to a bat or bitten by a bat. Patients may not be aware that they have been bitten in their sleep, and the bite may not be big. Waking up with a bat in the bedroom requires rabies prophylaxis.
D. Rodent transmission of rabies is unusual. Bites from any animal that can be observed for 2 weeks, such as pets or other domesticated animals, usually do not require rabies prophylaxis.
Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment Animal bites
Question 109
A patient is being discharged following treatment for excessive vomiting and diarrhea from a possible foodborne illness. You know the patient understands the discharge instructions when the patient states:
“Drinking milk will settle my stomach.”
“I will drink clear liquids, such as noncaffeinated sports drinks, for the next 24 hours.”
✓
“I will be able to eat my regular diet when I leave here.”
“Washing my fruits and vegetables before eating them is not necessary.”
Correct Answer
“I will drink clear liquids, such as noncaffeinated sports drinks, for the next 24 hours.”
A. Once vomiting has been controlled, oral hydration should begin with the use of fluids that contain glucose, sodium, and potassium, such as sports or electrolyte replacement drinks.
B. Institution of a regular diet following vomiting and diarrhea may induce the vomiting and diarrhea again. Patients should be instructed to gradually increase their diet as tolerated.
C. Milk or milk products are not recommended following vomiting and diarrhea.
D. When preparing fruits and vegetables, hands should be washed, and fruits and vegetables should be cleaned because they can be contaminated with Salmonella, E. coli, or Listeria.
Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Gastrointestinal, Genitourinary, Gynecology, and Obstetrical Emergencies, Gastrointestinal Cyclic vomiting syndrome
Question 110
The nurse is providing discharge education for an adult patient diagnosed with an infestation of Sarcoptes scabiei (scabies). Which of the following patient statements indicates that the patient understands the discharge instructions?
“I may continue to experience itching for up to 7 days following treatment.”
✓
“I should not go to work or school for 7 days following treatment.”
“I must discard all of my clothing and linens prior to treatment.”
“It is not necessary for my family members to receive treatment.”
Correct Answer
“I may continue to experience itching for up to 7 days following treatment.”
A. Patients may return to work or school after the first treatment for scabies.
B. Discarding clothing and linens is an option, but washing the items in hot water and then placing them in a hot clothes dryer is also acceptable.
C. It is common for patients to continue to have an itching sensation for up to 2–4 weeks following treatment. Patients should not be retreated without consulting their provider.
D. Scabies is highly contagious, and members of the household will most likely require treatment.
Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Animal bites (e.g., rabies, infection)
Question 111
A patient presents with fever and a small, flat, pink, nonpruritic macular rash on the palms of their hands and soles of their feet. The patient describes removing a tick from their forearm several days ago. Which tickborne disease would you suspect this patient has?
Tularemia
Rocky Mountain spotted fever
✓
Lyme disease
Colorado tick fever
Correct Answer
Rocky Mountain spotted fever
A. Patients with tularemia typically present with a skin lesion at the site of the bite, which may ulcerate in 2–3 days. Mild edema may be observed with regional adenopathy.
B. Patients with Rocky Mountain spotted fever typically have a fever along with a flat, pink, macular nonpruritic rash. The rash is generally on the palms, forearms, soles, and ankles and occurs within the first 10 days following the bite. The rash will initially blanche and then become raised bumps. Nausea with vomiting can also occur as a result of the disease process.
C. Lyme disease may present with a target or bull’s-eye rash with bright borders and a fading center. Patients present with malaise, viral syndrome, lymphadenopathy, and headache.
D. Patients with Colorado tick fever present with flulike illness, including fever, chills, malaise, myalgia, and lethargy. No rash is typically identified.
Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Animal bites (e.g., rabies, infection)
Question 112
A 14-year-old patient is being evaluated for symptoms of extreme fatigue, fever, sore throat, body aches, and rash, and there is a “knot” in the left axilla. You suspect the patient may have:
infectious mononucleosis.
✓
abscess to left axilla.
meningitis.
strep throat.
Correct Answer
infectious mononucleosis.
A. The presence of an isolated abscess to the left axilla would not cause the other associated symptoms the patient is experiencing. An abscess could be the cause of the swelling to the left axilla and fever but would not cause a sore throat or rash.
B. Symptoms of infectious mononucleosis include extreme fatigue, fever, sore throat, head and body aches, swollen lymph nodes in the neck and axilla, enlarged liver, enlarged spleen, and the presence of a fine red macular rash.
C. A beta-hemolytic streptococcal infection results in the symptoms associated with strep throat, which include fever, sore throat, and difficulty swallowing or talking; in addition, strep throat causes swelling to the cervical lymph nodes in the neck, not in the axilla.
D. Patients with meningitis may have symptoms of fatigue, fever, rash, body aches, and headache. Meningitis generally does not cause the patient to experience a sore throat or swollen lymph nodes in the axilla.
Category: Environment and Toxicology Emergencies, and Communicable Diseases, Communicable diseases, Hemorrhagic fevers
Question 113
In preparing the body of an organ donor for eye tissue donation, the nurse should perform which of the following?
Close the eyes and cover the eyelids with dry, sterile gauze
Prepare the patient for transfer to the operating room
Apply warm compresses to the eyelids to promote circulation
Elevate the head of the bed 20 degrees
✓
Correct Answer
Elevate the head of the bed 20 degrees
A. The eyelids should be taped shut with paper tape. Artificial tears may be instilled, but this is not required.
B. Cool compresses or ice should be applied to the eyelids to prevent swelling.
C. When corneas are to be donated, the head of the bed should be elevated at 20 degrees, and the eyelids should be taped shut with paper tape. Artificial tears may be instilled into the eyes, but this is not required.
D. Eye enucleation is a clean procedure, using sterile technique, that can be performed in any area of the hospital or at an outside mortuary.
Category: Professional Issues, Patient, End-of-life and palliative care (e.g., organ and tissue donation, advance directives, care withholding, family presence)
Question 114
The nurse is caring for a patient who had a tonic–clonic seizure and is now confused, appears anxious, and has noticeable hand tremors. Vital signs are BP 140/90 mm Hg, HR 128 beats/minute, RR 26 breaths/minute, SpO2 98%, T 37.4°C (99.3°F). The patient reports that they consume alcohol daily but stopped drinking alcohol about two days ago. What is the priority concern for this patient?
Injury
✓
Decreased cardiac output
Dehydration
Hallucinations
Correct Answer
Injury
A. This patient is at high risk for injury because of the potential for seizures, falls, confusion, and other alcoholic withdrawal complications. The first priority should always be patient safety.
B. The patient is at risk for decreased cardiac output if not treated for the alcohol withdrawal, but there are no signs and symptoms indicating an altered cardiac output.
C. Hallucinations are a concern for a patient experiencing alcohol withdrawal, but ensuring patient safety is a higher priority.
D. This patient is at risk for dehydration and will likely require fluid and electrolyte replacement; however, protecting the patient from injury is the highest priority.
Category: Medical Emergencies, Withdrawal syndrome
Question 115
Paramedics report that an adolescent patient was drinking an unknown amount of alcohol at a party. The patient is lethargic and only responds to painful stimuli by moaning. Vital signs are BP 110/60 mm Hg, HR 122 beats/minute, RR 14 breaths/minute, SpO2 94%, T 36.2°C (97.1°F). Which of the following diagnostic studies has the highest priority?
Serum glucose level
✓
Computed tomography of the head
Urine toxicology screen
Blood alcohol level
Correct Answer
Serum glucose level
A. Obtaining a serum glucose level is a priority to determine if hypoglycemia is present. Hypoglycemia is a common occurrence in alcohol toxicity, and it could also be the cause of the patient’s altered level of consciousness. Severe hypoglycemia can be fatal.
B. Computed tomography of the head is an appropriate diagnostic study, but it is not the highest priority.
C. A blood alcohol level will help to determine if alcohol abuse is the cause of the patient’s signs and symptoms, but it has limited value in patient management; therefore, it is not the priority diagnostic study.
D. Obtaining a urine toxicology screen to determine if the patient has used substances that may be causing the altered level of consciousness is appropriate but not the highest priority for this patient.
Category: Medical Emergencies, Substance use and abuse (e.g., alcohol and drug interactions, side effects, unintentional overdose)
Question 116
An adolescent is brought in from a “rave” party after experiencing a seizure. The patient is now confused and agitated. Vital signs are BP 180/98 mm Hg, HR 136 beats/minute, RR 26 breaths/minute, SpO2 97% without supplemental oxygen, T 39.6°C (103.2°F). Which of the following would be the first nursing intervention for this patient?
Initiate seizure precautions
✓
Initiate an intravenous line with a large-caliber catheter
Obtain a urine sample for analysis
Administer a short-acting benzodiazepine
Correct Answer
Initiate seizure precautions
A. Patient safety is the highest priority. The patient should be in a padded bed with side rails up and the bed placed in the lowest position.
B. Urine analysis and toxicology screen is indicated for this patient to determine the cause of the patient’s signs and symptoms, but it is not a priority intervention.
C. This patient will need an intravenous line, but ensuring a safe environment is the first action the nurse should take.
D. A short-acting benzodiazepine is indicated to stop the patient from actively seizing, but it would not be the first intervention that the nurse should complete.
Category: Medical Emergencies, Substance use and abuse (e.g., alcohol and drug interactions, side effects, unintentional overdose)
Question 117
A nurse is caring for a patient who was found lying on the floor for two days, following a fall. The patient’s skin assessment reveals an area of purple discoloration along the patient’s greater trochanter, which is boggy and warm to the touch. The nurse recognizes this wound as a(n):
area of ecchymosis.
stage 1 pressure ulcer.
potential deep tissue injury.
✓
stage 4 pressure ulcer.
Correct Answer
potential deep tissue injury.
A. A deep tissue injury is described as a purple or maroon localized area of discolored intact skin or blood-filled blister resulting from damage of underlying soft tissue from pressure and/or shear. This injury results from intense and/or prolonged pressure and shear forces at the bone–muscle interface.
B. Ecchymosis is the extravasation of blood into the tissues as a result of blunt-force impact to the body.
C. A stage 1 pressure ulcer is described as intact skin with nonblanchable redness of a localized area, usually over a bony prominence.
D. A stage 4 pressure ulcer is described as full-thickness tissue loss with exposed bone, tendon, or muscle.
Category: Musculoskeletal and Wound Emergencies, Wound, Avulsions and degloving injuries
Question 118
A motorcyclist arrives via ambulance following a collision with a motor vehicle. The patient was helmeted and wearing leather clothing, and was thrown across the hood of the car. The patient’s primary survey revealed no deficits; however, the secondary survey reveals pain, paresthesia, and weakness to the right arm and hand. There is no swelling, pallor, or coolness in the extremity. The nurse recognizes the patient has signs and symptoms of which of the following?
Compartment syndrome
Fracture of the humerus
Brachial plexus injury
✓
Brachial artery dissection
Correct Answer
Brachial plexus injury
A. The brachial plexus arises from the C5 to T1 spinal nerves. These nerves are responsible for supplying motor control and sensation to the arm, wrist, and hand. Injury to these spinal nerves will result in pain and paresthesia to the arm and wrist and hand weakness.
B. Compartment syndrome occurs when pressure increases within a fascial compartment. Signs and symptoms include pain out of proportion to the injury, pallor, decreased pulse, paresthesia, and paralysis, and the area feels firm to palpation.
C. Fractures must be ruled out. A fractured humerus would likely include deformity, ecchymosis, swelling, and inability to raise the arm.
D. Signs and symptoms of an arterial dissection may be similar to compartment syndrome with decreased radial pulses. It would be reasonable to rule out this injury with an arteriogram, but this patient does not have the key symptoms of swelling, pallor, or coolness of the extremity.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament tendon injuries (e.g., sprains, strains, ruptures)
Question 119
A patient has a severely increased thoracic curve, or “humpback.” What term will the nurse use to describe this condition?
Lordosis
Genu varum
Kyphosis
✓
Scoliosis
Correct Answer
Kyphosis
A. Kyphosis refers to an increased thoracic curvature of the spine, or “humpback.” Kyphosis (dowager’s hump) is a collapse of the spine that produces the appearance of a shortened trunk.
B. Lordosis is an increase in the lumbar curve, or swayback.
C. Genu varum is a bow-legged appearance of the legs in children.
D. Scoliosis is a lateral deformity, or curvature of the spine.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory conditions
Question 120
Which of the following conditions involves an insufficient amount of available antidiuretic hormone and results in the patient urinating large amounts of diluted urine?
Diabetes insipidus (DI)
✓
Cushing’s syndrome
Syndrome of inappropriate antidiuretic hormone (SIADH)
Adrenal crisis
Correct Answer
Diabetes insipidus (DI)
A. DI is a life-threatening condition caused by insufficient production of antidiuretic hormone (ADH) by the hypothalamus, or insufficient ADH being released by the posterior pituitary gland. The patient will excrete large amounts of dilute urine and complain of fatigue and weight loss. Treatment for DI is fluid replacement and ADH replacement with medications such as desmopressin acetate.
B. 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, an increase in potassium occurs, leading to hyperkalemia and the development of fatal dysrhythmias. Treatment includes fluid replacement, correction of hyperkalemia, and hydrocortisone administration.
C. SIADH is a life-threatening condition in which the pituitary gland releases excessive amounts of antidiuretic hormone. The patient will present with water intoxication and subsequent dilutional hyponatremia, which can result in seizures. The patient will also complain of headache, fatigue, and weight gain without the presence of edema. Treatment for SIADH depends on the severity of the patient’s hyponatremia. Fluid restriction should be initiated. Severe hyponatremia is treated with hypertonic saline and the administration of furosemide (Lasix).
D. Cushing’s syndrome is the result of prolonged exposure to glucocorticoids—either endogenous or exogenous—which causes the patient to develop a cushingoid appearance. There is an increased amount of adipose tissue in the face, upper back, and base of the neck.
Category: Medical Emergencies, Endocrine disorders
Question 121
Which assessment finding would be expected in a patient with adrenal crisis?
Hypokalemia
Bradycardia
Hyperglycemia
Hypotension
✓
Correct Answer
Hypotension
A. Patients in adrenal crisis have significantly low levels of cortisol and aldosterone. The risk of developing hypoglycemia, hyponatremia, hypovolemia/hypotension, and hyperkalemia is significant. The presence of hypotension should alert the nurse to the need for fluid resuscitation and immediate replacement of adrenal hormones.
B. Patients in adrenal crisis are at risk for hyperkalemia, not hypokalemia, because of the presence of insufficient adrenal hormones.
C. Patients in adrenal crisis are at risk for hypoglycemia, not hyperglycemia, because of the presence of insufficient adrenal hormones.
D. Because of severe hypotension, patients in adrenal crisis are often tachycardic and do not experience bradycardia.
Category: Medical Emergencies, Endocrine disorders
Question 122
A patient presents with a complaint of constant, sharp right-sided chest pain for the past 3 days. The pain is worse with breathing and arm movement. Vital signs are BP 108/70 mm Hg, HR 68 beats/minute, RR 18 breaths/minute, SpO2 99% on room air, T 37°C (98.6°F). The patient denies shortness of breath or recent trauma but reports a recent upper respiratory infection. The nurse anticipates interventions for which of the following?
Pericarditis
Anxiety
Pulmonary contusion
Costochondritis
✓
Correct Answer
Costochondritis
A. Pericarditis is inflammation of the pericardial layer of the heart and can be caused by bacterial, fungal, or viral infections, or the cause could be unknown. With pericarditis, the pain may be sharp, increase with movement, and be worse when the patient is lying down. In addition, the patient may have fever, fatigue, and possibly weight loss.
B. Pulmonary contusions are characterized by blood moving into the lung tissue following blunt-force trauma to the chest. Point tenderness over the site and dyspnea may be present, and the patient may complain of shortness of breath.
C. Anxiety can be a cause of chest pain and shortness of breath. If anxiety is suspected, a social history, recent stressors, and history of previous episodes of similar pain should be obtained.
D. Costochondritis is an inflammatory process of the costal cartilage and can present as sharp pain that is worse on palpation, inspiration, and expiration, and with cough or any movement. The reproducible pain can occur following an upper respiratory infection.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory conditions
Question 123
A patient presents with “aching” eye pain associated with the sudden onset of blurred vision after being hit in the eye with a ball. Visual acuity exam reveals no loss of vision. Which of the following complaints would cause the nurse the most significant concern?
A decreased ability to look upward
Cloudy appearance to the cornea
Increased lacrimation
Patient reporting that everything appears red
✓
Correct Answer
Patient reporting that everything appears red
A. Excessive tearing, exudates, or discharge from the eye is consistent with a foreign body or an eye infection or inflammatory process.
B. The decreased ability to look upward with the affected eye is a symptom of entrapment of extraocular muscles associated with an orbital fracture.
C. The presentation and symptoms are most consistent with a hyphema, blood in the anterior chamber of the eye. Patients may report “seeing red,” or blood-tinged vision. Excessive coughing, sneezing, or continually leaning forward can result in resumption of the bleeding, filling the entire anterior chamber of the eye with blood. As the outflow tracts clog with blood, anterior chamber pressure increases, which can lead to glaucoma and permanent vision loss.
D. A cloudy or hazy-appearing cornea is consistent with glaucoma.
Category: Maxillofacial and Ocular Emergencies, Ocular, Ocular trauma (e.g., hyphema, laceration, globe rupture)
Question 124
A geriatric patient presents with complaints of acute-onset blindness in the left eye. The patient reports two prior episodes that resolved after a few seconds and denies pain or recent trauma. The nurse anticipates the patient has experienced which of the following?
Retinal detachment
Central retinal artery occlusion
✓
Acute angle-closure glaucoma
Anterior uveitis
Correct Answer
Central retinal artery occlusion
A. Retinal detachment may be distinguished by the patient’s visual complaint, such as the presence of “floaters,” a “veil” or “curtain,” or flashes of light that affect their field of vision. A tear in the retina affects the eye’s ability to perceive light.
B. Acute angle-closure glaucoma is an increase in intraocular pressure. Symptoms include severe, sudden onset of eye pain, blurry vision, halos around lights, photophobia, and decreased visual acuity. If left untreated, it can result in permanent blindness.
C. Anterior uveitis is a painful inflammation that affects the uveal or middle layer of the eye. The affected eye is reddened with excessive tearing, and the patient will complain of photophobia. The eyelid will also appear edematous.
D. Central retinal artery occlusion (CRAO) is the sudden painless unilateral loss of vision caused by an embolus or thrombus. CRAO may be preceded by sudden temporary vision losses lasting seconds to minutes, which is referred to as amaurosis fugax.
Category: Maxillofacial and Ocular Emergencies, Ocular, Retinal artery occlusion
Question 125
A 3-year-old is being discharged with a diagnosis of conjunctivitis. The nurse knows that the parents understood the instructions when they state:
“My child may return to school tomorrow because it is only viral conjunctivitis.”
“My child may not attend daycare until the eye infection has resolved.”
✓
“My child may return to daycare when there is no crusting around the eyes.”
“My child may continue to sleep in the same bed with his brother.”
Correct Answer
“My child may not attend daycare until the eye infection has resolved.”
A. The child should not return to daycare until the redness and burning are resolved and there is no crusty discharge around the eyes upon awakening in the morning.
B. Bacterial and viral conjunctivitis are severely contagious, so the patient should not return to daycare until the infection has resolved. Strategies to reduce transmission are rigorous handwashing, not sharing towels and washcloths or pillows, and keeping the child out of the swimming pool.
C. Strategies to avoid spread of the disease include not sharing pillows, washcloths, or towels, and performing vigorous handwashing.
D. Bacterial and viral conjunctivitis are both severely contagious. The child should stay home until the redness and burning are resolved and there is no morning crusty discharge.
Category: Maxillofacial and Ocular Emergencies, Ocular, Ocular infections (e.g., conjunctivitis, iritis)
Question 126
A geriatric patient presents with complaints of a severe boring type of pain of the right eye, nausea, and seeing halos around objects. The patient was diagnosed with acute angle-closure glaucoma and received 500 mg of acetazolamide (Diamox) intravenously and 500 mg orally, and timolol (Timoptic) drops into the right eye. The nurse identifies that this therapy has been effective when which of the following occurs?
The patient’s intraocular pressure is 35 mm Hg.
The patient’s pain has resolved.
The patient’s nausea has resolved.
The patient’s intraocular pressure is 20 mm Hg.
✓
Correct Answer
The patient’s intraocular pressure is 20 mm Hg.
A. Normal intraocular pressure is 12–22 mm Hg. Intraocular pressure of 35 mm Hg indicates that continued treatment is needed.
B. Acute angle-closure glaucoma is defined as having at least two of the following symptoms: ocular pain, nausea/vomiting, and a history of intermittent blurring of vision with halos; and at least three of the following signs: intraocular pressure greater than 21 mm Hg, conjunctival injection, corneal epithelial edema, mid-dilated nonreactive pupil, and shallower chamber in the presence of occlusion. Acetazolamide and topical beta blockers are administered to decrease intraocular pressure.
C. Nausea often accompanies acute angle-closure glaucoma. Antiemetics should be administered because vomiting increases intraocular pressure.
D. Acetazolamide and topical beta blockers both work to decrease intraocular pressure, which may lessen the patient’s eye pain. However, the primary action is to lower the intraocular pressure.
Category: Maxillofacial and Ocular Emergencies, Ocular, Increased intraocular pressure
Question 127
A patient presents after being splashed in both eyes with a cleaning solution. During the assessment, the nurse notes the presence of bilateral corneal clouding and immediately initiates eye irrigation. The nurse knows that irrigation may be discontinued when:
1000 mL of irrigation solution has been used.
1 hour has passed.
the ocular pH reaches 7.0 in each eye.
✓
the pain in each eye has been relieved.
Correct Answer
the ocular pH reaches 7.0 in each eye.
A. Normal ocular pH is 7.0–7.4. Irrigation is performed until the ocular pH is within normal range.
B. The duration of irrigation is determined by a resulting normal pH, not the length of the irrigation. Depending on the chemical substance, irrigation may take more or less time before reaching normal ocular pH.
C. Relief of pain is not a determining factor in discontinuation of irrigation. Irrigation will continue until normal ocular pH has been achieved.
D. Volume of the irrigating solution is not a determining factor in discontinuation of irrigation. Irrigation will continue until normal ocular pH has been achieved.
Category: Maxillofacial and Ocular Emergencies, Ocular, Burns
Question 128
A patient with a history of diabetes presents with complaints of increasing left eye swelling and severe pain with movement of the eye. On assessment, the patient demonstrates decreased visual acuity, decreased pupillary reflexes, and erythema and edema of the eyelids and the left cheek area. The nurse recognizes that these signs and symptoms are consistent with:
iritis.
orbital cellulitis.
✓
anterior uveitis.
conjunctivitis.
Correct Answer
orbital cellulitis.
A. Conjunctivitis involves the eyelid and conjunctiva and results in redness, some edema, and drainage. Conjunctivitis does not affect the patient’s visual acuity. The patient will usually not experience pain with eye movement.
B. Anterior uveitis is the inflammation of all or part of the structures of the uveal tract (iris, ciliary body, choroid). It is associated with the presence of excessive tearing, redness of the eye, and decreased visual acuity. Pain will not be present with eye movement.
C. Iritis is the inflammation of the iris, resulting in pain, edema, tearing, and sensitivity to light, with some decrease in visual acuity. Pain is not present with eye movement.
D. Orbital cellulitis is a serious emergency that involves the eye itself. It results in painful movement, reduced visual acuity, and severe swelling and redness of the orbital area. Patients who are immunocompromised or who have a history of diabetes are more susceptible to complicating infections. Orbital cellulitis is a potentially life-threatening infectious process because of the potential for the infection to enter the brain, resulting in meningitis.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Maxillofacial infections (e.g., Ludwig’s angina, otitis, sinusitis, mastoiditis)
Question 129
A patient presents to triage complaining of pain in the right distal forearm after falling onto their outstretched arm. There is an obvious deformity above the patient’s right wrist. Right radial pulse is present, and color and sensation are intact distally; however, the patient is unable to sustain a wrist grip. The nurse is aware that it is best to immobilize the right forearm using a(n):
ice pack and elastic bandage.
traction splint.
pillow and sling.
padded rigid long arm splint.
✓
Correct Answer
padded rigid long arm splint.
A. Traction splints are used for actual or potential femur or proximal tibial fractures and would not be indicated for an upper extremity injury.
B. Splinting of the extremity is indicated when there is evidence of deformity, pain, bony crepitus, edema, ecchymosis, open soft-tissue injury, paralysis, or paresthesia. Always immobilize joints above and below a suspected fracture site.
C. Soft splints include pillows and slings and could be an option if a rigid splint is not available. The presence of an obvious deformity makes the use of a rigid splint the best choice of treatment for this patient.
D. Application of ice and elevation are indicated to reduce swelling and pain but will not provide immobilization of the extremity. A rigid splint is the best choice for the immediate treatment of this patient.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures (e.g., open, closed, fat embolus)
Question 130
A patient presents with possible signs and symptoms of compartment syndrome 2 days after surgery for a fractured left tibia/fibula. Which of the following would alert the nurse that this patient may be experiencing a worsening complication?
Generalized edema
Rales
Jaundice
Dark, scanty urine
✓
Correct Answer
Dark, scanty urine
A. Rales are an indication of fluid collecting in the lungs. Compartment syndrome does not result in the presence of rales.
B. Jaundice is caused by the presence of an excessive amount of bilirubin in the blood. Compartment syndrome results in poor skin color (pallor) and cool temperature, indicating poor perfusion; it does not result in jaundice.
C. Compartment syndrome can lead to rhabdomyolysis, which is significant muscle damage and cellular destruction resulting in the release of myoglobin, a muscle protein, into the bloodstream. As the myoglobin enters the kidneys, it causes the appearance of dark red or brown urine. The myoglobin can also clog the renal glomerulus, resulting in an acute renal injury. If the myoglobin is not flushed from the kidneys with large amounts of fluid, permanent renal impairment or injury can result.
D. The compartment or limb of the affected extremity will feel tight or tense on palpation. The skin may appear taut and shiny as the skin stretches. This edema is localized to the affected extremity and is not generalized.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Compartment syndrome
Question 131
A patient presents to triage with a complaint of a headache, and appears anxious and restless. The patient reports that the “man at the desk” has followed him from Russia, where he worked for the Central Intelligence Agency, and that the headache began after the tracking chip implanted in his brain was activated. The patient has identification indicating a local address, and there is no indication of recent travel or other corroboration of the information. The nurse suspects that the cause of the patient’s symptoms is related to:
an anxiety attack.
migraine headache.
psychosis.
✓
dementia.
Correct Answer
psychosis.
A. Anxiety attacks are characterized by tachycardia, palpitations, hyperventilation, and diaphoresis. Although the patient is anxious, it appears that he is having other symptoms that do not correspond to anxiety and indicate a more severe mental illness.
B. Other than the report of a headache, no other signs or symptoms are consistent with migraine, such as a throbbing pain, photophobia, or nausea.
C. A patient with dementia will appear disoriented, repeat the same information, have difficulty finding the right words to express their thoughts, and not be able to follow a conversation. Although the patient is confused, a dementia diagnosis does not adequately explain their other symptoms.
D. Psychosis is a severe mental disorder in which a person loses the ability to recognize reality or relate to others. Symptoms include being paranoid, having false ideas about what is taking place or who one is, and seeing, hearing, or feeling things that are not there. Other associated mental disorders are schizophrenia and bipolar disorder.
Category: Mental Health Emergencies, Thought disorders (e.g., psychosis, schizophrenia)
Question 132
A patient reports a history of generalized anxiety disorder that is controlled with 0.5 mg of alprazolam (Xanax) 3 times daily as needed. Which of the following patient statements requires additional follow-up and patient education by the nurse?
“I eat a lot of dairy products frequently and sometimes take the Xanax with milk.”
“I do not take the Xanax every day.”
“I only take the Xanax before participating in stressful events to prevent anxiety.”
“I drink several glasses of wine in one setting on a regular basis.”
✓
Correct Answer
“I drink several glasses of wine in one setting on a regular basis.”
A. The medication is prescribed “as needed,” so the patient is correct to take it only when needed.
B. Taking Xanax proactively instead of reactively is appropriate use of the medication and may help prevent dependence.
C. Xanax is a benzodiazepine. Alcohol may intensify the effects of benzodiazepines, increasing the risk of falls and respiratory depression. The patient should be cautioned not to drink alcohol with the medication.
D. There is no contraindication to combining dairy products with benzodiazepines.
Category: Mental Health Emergencies, Anxiety disorders (e.g., PTSD, anxiety, panic attack)
Question 133
An elderly patient arrives via emergency medical services with profuse epistaxis that has persisted for over an hour. After initiating universal precautions, the next priority intervention for the nurse to perform is which of the following?
Obtain blood pressure
Initiate direct pressure by instructing the patient to pinch their nostrils
Maintain airway patency
✓
Initiate intravenous access
Correct Answer
Maintain airway patency
A. Although vital signs are important to obtain, they should never take priority over assessing airway patency.
B. This patient will need intravenous hydration because of the duration of the bleeding and suspected blood loss, but assessing and maintaining airway patency is the first priority.
C. Posterior nasal bleeding can interfere with a patient’s airway patency. Posterior bleeding can be chronic and is most common in elderly patients who may have a history of hypertension and who take an anticoagulation-type medication.
D. This maneuver is effective with anterior nasal bleeds but will not act to minimize the amount of bleeding in a posterior nasal bleed. Anterior nasal bleeds usually arise from the area of the Kiesselbach plexus. This patient is demonstrating signs and symptoms of a posterior bleed.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Epistaxis
Question 134
What is the priority assessment for a patient who has sustained a traumatic laceration to the upper arm?
Skin color and temperature
Distal or radial pulse
✓
Range of motion in the fingers
Capillary refill
Correct Answer
Distal or radial pulse
A. Finger range of motion will indicate whether there is tendon involvement; however, this is not the priority assessment.
B. Lack of a distal pulse indicates vascular compromise to the arm and requires immediate intervention to preserve limb function.
C. The presence of capillary refill will indicate adequate or decreased perfusion to the arm, but the presence of a radial pulse is a more reliable indicator of adequate tissue perfusion.
D. Skin color, temperature, and moisture will indicate adequate or decreased perfusion to the arm, but the presence of a radial pulse is a more reliable indicator of adequate tissue perfusion.
Category: Musculoskeletal and Wound Emergencies, Wound, Lacerations
Question 135
Which wound is the highest risk for development of osteomyelitis?
Stage 1 pressure injury to the heel
Laceration to the elbow from breaking glass
Laceration to the palmar surface of the hand from a carving knife
Deep puncture wound in the foot from stepping on a nail
✓
Correct Answer
Deep puncture wound in the foot from stepping on a nail
A. This is not a high-risk wound for developing osteomyelitis.
B. A stage 1 pressure wound on a heel is not at high risk for developing osteomyelitis.
C. A laceration from breaking glass is not a high-risk wound for the development of osteomyelitis.
D. A puncture wound of the foot is associated with deep penetration resulting from weight bearing on a sharp object, with frequent penetration of a metatarsal bone. The patient will complain of pain, redness, and swelling within 4–7 days following injury as the infection begins to develop.
Category: Musculoskeletal and Wound Emergencies, Wound, Wound infections
Question 136
The nurse is preparing to discharge a patient who has received treatment to close a facial laceration. The nurse recognizes the patient’s understanding of the discharge instructions when the patient states:
“I will be sure to call my doctor in the morning for a prescription for an antibiotic.”
“I will be sure to have my staples removed after 1 week.”
“I will return to the emergency department in 14 days for suture removal.”
“I need to place a thin layer of antibiotic ointment over the sutures daily.”
✓
Correct Answer
“I need to place a thin layer of antibiotic ointment over the sutures daily.”
A. Uncomplicated wounds in a healthy individual do not usually require systemic antibiotics.
B. The application of antibiotic ointment will help to prevent wound infection.
C. Staple wound closures are limited to areas where a scar will not be apparent and therefore are not indicated for facial wounds.
D. Facial sutures are typically removed in 3–5 days. Sutures over joints require 14 days to heal before removal.
Category: Musculoskeletal and Wound Emergencies, Wound, Wound infections
Question 137
A patient reports that while descending from a ladder, they unintentionally fired a nail gun into their right thigh. Immediately following, the patient was unable to straighten their leg, and their coworkers had to cut the patient’s jeans off from around the nail head. A radiograph reveals the presence of a foreign body embedded in the patient’s right femur. The nurse anticipates that this injury will be managed as a(n):
open fracture.
✓
foreign body.
comminuted fracture.
high-pressure injection injury.
Correct Answer
open fracture.
A. Though there is a foreign body present, since it is embedded in the bone, there is now a fracture. And since the nail pierced the skin to get there, it is considered an open fracture and should be treated that way.
B. An injury is classified as an open fracture if a penetrating foreign body enters the bone or creates an opening in the tissue directly over the bone.
C. Comminuted fractures occur from severe direct trauma to the bone and result in more than two bone fragments.
D. High-pressure injection injuries occur when air or liquids, such as paint, grease, or fuel oils, enter the skin under immense pressure through a small hole and cannot escape. Treatment for this injury is very different from an open fracture.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures (e.g., open, closed, fat embolus)
Question 138
A parent presents to triage with a toddler, stating that the child fell while walking and now will not move their left arm. However, the child fell on their right side. What should the triage nurse do next?
Suspect child maltreatment because the story does not match the injury
Ask the parent if the left arm was held to try and prevent the fall
✓
Obtain a radiograph of the right arm per standing orders
Assess the injured left arm by using passive range of motion
Correct Answer
Ask the parent if the left arm was held to try and prevent the fall
A. A radiograph study is frequently unwarranted in radial subluxation. The diagnosis of radial subluxation can be made by physical examination. The subluxation can be easily relocated with good return of function. It is not necessary to immobilize the extremity following relocation of the subluxation.
B. In this case, the concern of child maltreatment may or may not match the history of the event. The nurse should further assess the situation to determine if the concern for maltreatment is warranted. However, the first priority is to assess for the presence of possible radial head subluxation injury (nursemaid’s elbow).
C. Assess for the presence of possible radial head subluxation injury (nursemaid’s elbow) caused by pulling on the child’s arm to prevent them from falling. Subluxation is partial joint disruption (partial dislocation) that maintains some contact with the articulating surfaces. In children under the age of 5, radial head subluxation is present in approximately 20% of upper extremity injuries.
D. If the arm is fractured, it is not best practice to use passive range of motion to assess the extremity. If a radial head subluxation is present, a patient reduction of the partial dislocation should be performed by the emergency care provider. Reduction of the subluxation is not within the scope of practice for an emergency nurse.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures (e.g., open, closed, fat embolus)
Question 139
When providing discharge instructions to the parents of a child, the nurse is aware that the parents have understood the importance of avoiding products that contain aspirin when they state which of the following?
“Aspirin usage in febrile children is associated with the development of asthma.”
“Aspirin is less effective in controlling fevers in children because of their immature neurologic system.”
“Aspirin may make them ill if I give it while they have a fever and a virus.”
✓
“Aspirin may cause an increased risk of febrile seizures, given its slower onset of action.”
Correct Answer
“Aspirin may make them ill if I give it while they have a fever and a virus.”
A. Aspirin-containing products should not be given to children with an acute febrile illness because of their association with the development of Reye’s syndrome, a rare yet rapidly progressing syndrome that results in encephalopathy. Other factors associated with the syndrome include use of aspirin during a viral illness, after which fatty deposits in the liver lead to altered mental status and altered glucose regulation.
B. The immature pediatric neurologic system increases the risk for febrile seizures. Aspirin is an effective antipyretic but is contraindicated for use in the pediatric population, given the potential risk of developing Reye’s syndrome.
C. Aspirin has a similar onset of action compared with other antipyretics but is contraindicated because of the risk of developing Reye’s syndrome. The immature neurologic system in the younger child increases the risk for febrile seizures.
D. Aspirin is a known trigger for asthma in some patients but has not been shown to increase the incidence of asthma. The use of aspirin is contraindicated, given the risk of Reye’s syndrome in febrile children.
Category: Medical Emergencies, Sepsis
Question 140
A patient arrives via emergency medical services with sudden onset of altered level of consciousness. The patient was found wandering at the local bus station, is able to answer questions only after much thought, and is unable to recognize that they are currently in a hospital. The patient appears very anxious, is diaphoretic, and has uncontrolled tremors to bilateral arms. Which of the following diagnostic tests would be the first priority for the nurse to obtain in order to assist in proper diagnosis of this problem?
White blood cell count
Serum glucose
✓
Urinalysis
Serum creatinine
Correct Answer
Serum glucose
A. A serum creatinine would provide information regarding the patient’s renal status, but it takes longer to receive the result; a point-of-care blood glucose value can be obtained much more quickly.
B. A urinalysis will provide information regarding a urinary tract infection that might lead to the subsequent development of sepsis; however, this diagnostic test requires time and would not provide immediate feedback. Sepsis could present with an altered level of mentation, but hypoglycemia is a more likely cause of the patient’s symptoms.
C. A complete blood cell count, which would include a white blood cell count to indicate a possible infectious process, would be appropriate but is not a first-line priority in this case; point-of-care blood glucose would provide the most important information.
D. Any patient with an altered level of consciousness should have an immediate blood glucose level performed to rule out the presence of hypoglycemia. This patient is presenting with classic signs of hypoglycemia. Hypoglycemia is one of the most common causes of altered level of consciousness and can be easily treated.
Category: Medical Emergencies, Endocrine disorders
Question 141
A patient complains of transient palpitations and occasional numbness and tingling of their fingers and nose. While vital signs are being obtained, the nurse observes a sudden onset of carpal spasms on the arm on which the blood pressure cuff is being inflated. The nurse recognizes that this finding is consistent with the presence of:
hypocalcemia.
✓
hyperkalemia.
hypokalemia.
hypercalcemia.
Correct Answer
hypocalcemia.
A. Hypocalcemia results in excitation of the nervous system, including tetanic contractions of skeletal muscle. This response is referred to as Trousseau’s sign.
B. Hypercalcemia generally presents with muscle weakness and depressed deep tendon reflexes.
C. This particular response is not related to hypokalemia. Hypokalemia may present with hyporeflexia.
D. This particular response is not related to hyperkalemia. Hyperkalemia may present with muscle weakness and flaccid paralysis.
Category: Medical Emergencies, Electrolyte and fluid imbalance
Question 142
Which of the following laboratory test values would alert a nurse that a patient with disseminated intravascular coagulation (DIC) is beginning to improve?
Prolonged partial thromboplastin time
Increased platelet count
✓
Increased prothrombin
Elevated D-dimer
Correct Answer
Increased platelet count
A. DIC can cause an elevation in both D-dimer and fibrin degradation factor. A continual D-dimer increase would indicate progression of the disease, not an improvement in the patient’s DIC.
B. DIC causes a massive consumption of platelets, which leads to the extensive clotting that occurs; therefore, an increase in the patient’s platelet count would indicate that the DIC is lessening, and the patient is beginning to improve.
C. The pathophysiology of DIC is one of a prolonged partial thromboplastin time (PTT); therefore, a continued prolonged PTT would not indicate improvement in the patient’s condition, but rather that the DIC is continuing.
D. An increase or prolongation of the prothrombin would be a pathophysiological response, not a physiological response, and therefore would not indicate patient improvement.
Category: Medical Emergencies, Hematologic disorders
Question 143
A patient presents to triage with a complaint of chest pain, shortness of breath, fever, cough, and wheezing. The patient is tachypneic and has diminished breath sounds. The patient’s medications include lisinopril, metformin, and hydroxyurea. The patient is a poor historian and is refusing to answer questions. The nurse should be most concerned about which potential diagnosis for this patient?
Acute chest syndrome
✓
Superior vena cava syndrome
Acute myocardial infarction
Chronic obstructive bronchitis
Correct Answer
Acute chest syndrome
A. The patient presentation and current medication history (hydroxyurea) are consistent with a diagnosis of sickle cell disease (SCD). SCD is a hereditary disorder that affects primarily African Americans and those of Mediterranean descent. Acute chest syndrome (ACS) is a vaso-occlusive crisis occurring in the lung tissue and is one of the leading causes of mortality in patients with SCD. Symptoms of ACS include chest pain, dyspnea, cough, and hypoxemia, accompanied by wheezing, diminished breath sounds, and pulmonary infiltrates visible on chest radiograph. ACS can quickly progress to acute pulmonary failure. Hydroxyurea stimulates the production of fetal hemoglobin, providing for increased oxygen-carrying hemoglobin in the patient, and is an effective treatment modality for some patients with SCD.
B. Fever, cough, and wheezing are not usually associated with the presence of an acute myocardial infarction.
C. Chronic obstructive bronchitis, a component of chronic obstructive pulmonary disease, does not usually present with chest pain or fever. The adventitious sound that is normally heard with this process is rhonchi. Wheezing can be associated with emphysema, another component of chronic obstructive pulmonary disease.
D. Superior vena cava syndrome is a cancer complication that occurs when a mass obstructs the superior vena cava. An obstruction occurs either inside or outside the vena cava and results in reduced blood flow back to the heart. Symptoms include facial, neck, and arm swelling, chest pain, shortness of breath, and hoarseness. Cerebral edema and airway obstruction can also occur. Fever and wheezing are not symptoms of superior vena cava syndrome.
Category: Medical Emergencies, Hematologic disorders
Question 144
Parents report that their adolescent has demonstrated recent behavior changes, including extreme anger with family members, no desire to complete required tasks (attend school or do chores), racing thoughts with rapid speech, and impulsive actions. The nurse suspects which psychiatric disorder is being demonstrated by the patient?
Psychosis
Bipolar disorder
✓
Panic disorder
Attention-deficit hyperactivity disorder
Correct Answer
Bipolar disorder
A. Psychosis is an altered mental state in which the child experiences a variety of disturbances that affect their perceptions of reality. The presentation includes hallucinations, delusions, and disorganized speech patterns. New-onset psychosis in children is uncommon but may be seen with other psychiatric disorders such as severe anxiety, posttraumatic stress disorder, or depression, or it can be related to an organic cause.
B. Attention-deficit hyperactivity disorder (ADHD) is characterized by symptoms of inattention, hyperactivity, and impulsiveness. The child may frequently interrupt or intrude on others, have trouble completing tasks, or become easily distracted. It is estimated that two children in every classroom have been diagnosed with ADHD.
C. Bipolar disorder is seen in many children who display inability to function in daily life because of frequent mood swings, often going from a depressive state to a manic state (speaking quickly or racing thoughts). Children will lose the ability to complete daily tasks, such as going to school and completing chores, and they may experience mood swings with varying severity depending on the age of the child.
D. Panic disorder is a severe form of anxiety. The presentation includes crying, possibly clinging to a parent or loved one, symptoms of chest pain or discomfort, choking sensation, sweating, dizziness, lightheadedness, fear of dying, and a racing pulse.
Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 145
When suspecting the presence of child maltreatment or neglect in a patient, the nurse is required to:
review the pediatrician or family physician records.
document the names of the suspected abusers in the medical record.
inform the parent of the police notification.
report the suspected abuse or neglect to the police and child protective services.
✓
Correct Answer
report the suspected abuse or neglect to the police and child protective services.
A. Documentation of facts is important in the potential child maltreatment or neglect case. The name of the abuser may or may not be known; however, the proper local authorities must be notified of the suspected abuse or neglect.
B. In some cases, notification of the report to the parent/guardian may not be beneficial to the welfare of the child. The parent may attempt to leave the emergency department if notified of the report to police or child protective services.
C. Nurses are mandatory reporters for suspected child maltreatment or neglect. Failure to report may result in possible civil or criminal charges being brought against the nurse.
D. A child’s prior pediatrician records or visits may be researched in a case of child maltreatment or neglect, but only after obtaining permission from the provider. Nurses are mandated to report to the police and child protective services in all cases of suspected abuse or neglect.
Category: Professional Issues, Patient, Abuse and neglect
Question 146
A 20-kg child presents with a 2-day history of vomiting and diarrhea. The child is now being orally rehydrated and is ready for discharge home with the parents. Which of the following would be most important to include in the home care discharge instructions?
Administer small amounts (1 teaspoon) of apple juice at frequent intervals
Administer small amounts (1 teaspoon) of clear liquids at frequent intervals
✓
Resume normal meals in small amounts
Start a BRAT (bananas, rice, applesauce, toast) diet
Correct Answer
Administer small amounts (1 teaspoon) of clear liquids at frequent intervals
A. Oral rehydration therapy can be continued at home. The parents should be instructed to administer the solution in sips of 1 to 2 teaspoons every 5 minutes to promote absorption and prevent vomiting.
B. After 2 days of vomiting and diarrhea, the priority for this patient is oral rehydration. The reintroduction of solid food too quickly is likely to induce additional vomiting.
C. Rehydration is the priority for this child, so initial home care instructions should include the administration of an oral rehydration solution. Also, studies have shown that children fed their regular diet (instead of the BRAT) return to their pre-illness weight sooner than those who are diet restricted.
D. Apple juice should be avoided because it is hyperosmolar and may worsen diarrhea.
Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Cyclic vomiting syndrome
Question 147
An older adult patient presents after demonstrating aggressive behavior in the patient’s group home residence. The patient is pale, diaphoretic, and displaying tonic–clonic movement. Which laboratory test has the highest priority for this patient?
Blood glucose level
✓
Venous blood gas
Blood alcohol level
Sodium level
Correct Answer
Blood glucose level
A. Though a venous blood gas can usually be obtained fairly quicky, alterations will usually present with respiratory signs and symptoms and not with seizure-like activity. Checking blood sugar is the highest-priority lab for this patient.
B. Obtaining a blood glucose level has the highest priority for this patient and is one of the fastest laboratory tests to obtain. The presence of hypoglycemia is a frequent cause of seizures and acute mental status changes.
C. A blood alcohol level is not a priority for this patient. Alcohol is a sedative, and seizures most often only occur in the presence of alcohol withdrawal.
D. Though altered sodium levels may be a cause of seizure-like activity, obtaining a glucose level has the highest priority for this patient.
Category: Medical Emergencies, Endocrine disorders
Question 148
Which of the following is a late sign of increased intracranial pressure in a patient with a large subarachnoid hemorrhage?
Sluggish pupils
Behavioral changes
Narrowing pulse pressure
Bradycardia
✓
Correct Answer
Bradycardia
A. Fixed and/or dilated pupils would be a late sign of increased intracranial pressure. Late signs of intracranial pressure include the presence of Cushing’s triad: (1) bradycardia, (2) widening pulse pressure, and (3) abnormal respirations. In addition, late signs of intracranial pressure may include unresponsiveness and posturing. Early signs of intracranial pressure include headaches, nausea/vomiting, changes in mental status, and behavioral changes.
B. A widened pulse pressure, not a narrowing pulse pressure, would be a late sign of increased intracranial pressure. Late signs of intracranial pressure include the presence of Cushing’s triad: (1) bradycardia, (2) widening pulse pressure, and (3) abnormal respirations. In addition, late signs of intracranial pressure may include unresponsiveness, dilated nonreactive pupils, and posturing. Early signs of intracranial pressure include headaches, nausea/vomiting, changes in mental status, and behavioral changes.
C. Late signs of intracranial pressure include the presence of Cushing’s triad: (1) bradycardia, (2) widening pulse pressure, and (3) abnormal respirations. In addition, late signs of intracranial pressure may include unresponsiveness, dilated nonreactive pupils, and posturing. Early signs of intracranial pressure include headaches, nausea/vomiting, changes in mental status, and behavioral changes.
D. Behavioral changes would be considered an early sign of increased intracranial pressure. Late signs of intracranial pressure include the presence of Cushing’s triad: (1) bradycardia, (2) widening pulse pressure, and (3) abnormal respirations. In addition, late signs of intracranial pressure may include unresponsiveness, dilated nonreactive pupils, and posturing. Early signs of intracranial pressure include headaches, nausea/vomiting, changes in mental status, and behavioral changes.
Category: Neurological Emergencies, Stroke
Question 149
When caring for an adult patient with Alzheimer’s dementia, the nurse is aware that a patient with mild dementia will exhibit which of the following symptoms?
Difficulty handling finances
Short-term memory loss
✓
Episodes of wandering
Loss of facial recognition
Correct Answer
Short-term memory loss
A. Episodes of wandering start to appear in the moderate stage of dementia, which is several years after the onset.
B. Difficulty handling money and finances, as well as disorientation to time, place, and events, presents during the moderate stage of dementia.
C. Short-term memory loss is usually the first sign of dementia and is often overlooked or discounted.
D. Agnosia is the inability to recognize familiar objects, places, or people. Loss of facial recognition is usually seen in the severe stage.
Category: Neurological Emergencies, Neurological disorders (e.g., multiple sclerosis, myasthenia gravis, Guillain–Barré syndrome)
Question 150
A patient with a recent history of anterior myocardial infarction (MI) develops severe shortness of breath. Crackles are noted bilaterally on auscultation. An echocardiogram shows an ejection fraction of 30%. The nurse is concerned that the patient may have decompensated heart failure progressing to cardiogenic shock. What is the priority intervention in this situation?
Furosemide (Lasix) administration
Dobutamine infusion
Bilevel positive airway pressure (BiPAP)
✓
Nitroglycerin infusion
Correct Answer
Bilevel positive airway pressure (BiPAP)
A. In patients with decompensated heart failure, decreasing afterload by initiating a nitroglycerin infusion to vasodilate may decongest the lungs, reduce workload on the heart, and improve cardiac output. However, the patient’s blood pressure must tolerate the afterload reduction. The patient’s blood pressure is not known in this scenario, so this would not be the priority intervention.
B. In decompensated heart failure, the patient may be at risk for fluid overload. It is important for hemodynamic stability to optimize fluid status in these patients. Administration of a diuretic such as furosemide (Lasix) will help with removal of fluid. However, based on the severity of the patient’s pulmonary symptoms, it is important to treat the lungs first in this scenario. BiPAP will treat the pulmonary congestion more rapidly then furosemide, which takes more time to take effect.
C. BiPAP helps to reduce afterload, reduce preload, and improve work of breathing. BiPAP can reduce the demand on the heart by helping the weakened left ventricle generate enough pressure to move the blood forward. In this scenario, the priority is to treat the lungs, and BiPAP is effective in rapidly improving pulmonary symptoms.
D. Dobutamine is a positive inotrope that can help improve contractility (squeeze) of the heart. A patient with decompensated heart failure and a low ejection fraction may need an inotrope to help squeeze the heart in order to move the blood forward. This will help prevent backup of fluid into the pulmonary system, which can cause pulmonary congestion and symptoms. However, dobutamine should be used only for patients with refractory pulmonary edema who do not respond to nitroglycerin or diuresis, or hypotensive patients, for whom nitroglycerin or diuretics are contraindicated. This would not be the priority intervention in this scenario.
Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock