CEN Sample Test 1 with Rationale

Completing a full set of CEN Test Questions can simulate a real exam experience.

BCEN Sample Test 1 with Rationale

Question 1.
An unrestrained passenger is thrown 20 feet (6 m) from a car that hit an embankment. On arrival to the emergency department, the patient is conscious and complains of shortness of breath. His vital signs are as follows: blood pressure 108/66 mm Hg, pulse 116 beats/minute with weak radial pulses, and respirations 26 breaths/minute and shallow. Capillary refill is delayed. The lungs are clear bilaterally with diminished breath sounds on the right. Paradoxical chest movement is noted on the right side. A chest radiograph shows a right pneumothorax and multiple rib fractures on the right (fourth to seventh). Which of the following potential injuries would be the trauma nurse’s primary concern for this patient?
(a) Flail chest 
(b) Tension pneumothorax 
(c) Ruptured diaphragm 
(d) Massive hemothorax
Answer:
(a) Flail chest 

Nursing Process: Assessment/Respiratory 

Rationale: 
Fail chest is caused by two or more fractures of two to three or more adjacent ribs. These fractures do not move with the chest wall during respiration. Signs include paradoxical movement of the chest wall during inspiration and expiration, ineffective ventilation, and dyspnea. Although flail chest can also cause a tension pneumothorax' this is not the primary concern for the trauma nurse. Classic signs of a tension pneumothorax include tracheal deviation, cyanosis, severe dyspnea, absent breath sounds on the affected side, distended jugular veins, and shock. The patient with a ruptured diaphragm will present with hypotension, dyspnea, dysphagia, shifted heart sounds, and bowel sounds in the lower to middle chest. A patient with a massive hemothorax will show signs of shock (tachycardia and hypotension), dullness on percussion on the injured side, decreased breath sounds on the injured side, respiratory distress, and, possibly, a mediastinal shift.

Question 2.
A 24-year-old patient is in the early stage of an acute asthma attack. Knowing the pathology of asthma and the progression of an asthma attack and its correlation with arterial blood gases (ABGs), the emergency nurse anticipates which of the following ABG results on this patient?
(a) Normal pH, normal PaCO₂, and normal PaO₂ 
(b) Elevated pH, decreased PaCO₂, and decreased PaO₂ 
(c) Decreased pH, increased PaCO₂, and decreased PaO₂ 
(d) Normal pH, normal PaCO₂, and decreased PaO₂
Answer:
(b) Elevated pH, decreased PaCO₂, and decreased PaO₂ 

Nursing Process: Analysis/Respiratory 

Rationale: 
Early in an acute asthma attack, respiratory alkalosis should be present, which should be evident with a pH greater than 7.45 and a decreased PaCO₂ (hypocarbia) because the carbon dioxide is being blown off at an increased rate. A low PaO₂ (hypoxemia) should be present if a true asthmatic event is occurring. Acidosis indicated by a decreased pH (lower than 7.35) would be present in a patient with hypoventilation, which would be demonstrated by an increased PaCO₂. Normal readings on the arterial blood gas report would not indicate an asthma attack.
 
Question 3.
Which of the following is the most common area of rupture in traumatic cardiac injury?
(a) Aortic arch 
(b) Pulmonary vein 
(c) Ligamentum arteriosum 
(d) Right coronary artery
Answer:
(c) Ligamentum arteriosum 

Nursing Process: Analysis/Cardiovascular 

Rationale: 
Traumatic thoracic injury can cause aortic injury and the tear most commonly occurs at the ligamentum arteriosum (80% to 90%). This is a band of tissue that forms about 3 weeks after birth and is a vestige of the fetal ductus arteriosus. It connects the aorta to the pulmonary artery and when torn has usually fatal outcomes. If a complete tear does not occur and the adventitial layer of the vessel (the outermost layer) remains intact, an aneurysm can develop.

Question 4.
A patient arrives with a history of surgery 3 weeks ago and now has complaints of leg swelling, redness, warmth, and tenderness. The emergency nurse suspects which of the following?
(a) Postthrombotic syndrome (PTS)
(b) Thromboangiitis obliterans (Buerger disease)
(c) Peripheral venous thrombosis
(d) Raynaud’s disease
Answer:
(c) Peripheral venous thrombosis

Nursing Process: Assessment/Cardiovascular 

Rationale: 
Peripheral venous thrombosis (also known as deep vein thrombosis or DVT) is an occlusion of a vein by a thrombus restricting blood outflow. The majority of DVTs involves the lower extremities and triggers include hypercoagulable/immobile states such as cancer, pregnancy, sepsis, surgery, and/or trauma. Signs and symptoms vary, but include swelling; pain, tenderness, and warm, red, or discolored skin. Post-thrombotic syndrome is considered the most common long-term complication of a DVT and manifests up to 2 years later as chronic venous insufficiency varying from minor leg discomfort or swelling up to venous claudication and skin ulcerations.

Thromboangiitis obliterans or Buerger's disease is an occlusive, chronic, inflammatory disorder of the arteries, veins, and surrounding nerves that trigger decreased blood flow in the hands and feet resulting in ischemia and pain. Intermittent claudication and decreased or absent peripheral pulses lead to ulcers and gangrene may develop. Raynaud’s disease produces vasospasms that reduce blood flow to the arteries of the hands and feet in response to a trigger such as cold temperatures or smoking; symptoms are pallor and numbness/tingling that returns to normal after the stimulus is removed.

Question 5.    
A patient presents to the emergency department following a fall from a porch 3 days before. He is pale and diaphoretic and states that he feels short of breath. On assessment, he has tenderness to the right lower anterior ribs. Bilateral, clear, equal breath sounds are present. Vital signs are as follows:
Blood pressure—88/62 mm Hg 
Pulse—134 beats/minute 
Respirations— 32 breaths/minute 
Pulse oximetry—92 % on room air 
Temperature—98.4° F (36.8° C)

Which of the following diagnoses should the emergency nurse anticipate?
(a) Splenic injury 
(b) Colon injury
(c) Cardiac injury    
(d) Liver injury
Answer:
(d) Liver injury

Nursing Process: Assessment/Gastrointestinal 

Rationale: 
Right lower rib fractures can cause liver injury, especially with fractures from the eighth rib down. Emergency personnel should be aware of this as a mechanism of injury and be alert to the possibility. This patient is demonstrating signs of hypovolemic shock and a major clue should be the tenderness to the right lower rib area along with the vital signs and the fall from the porch. Splenic injuries can occur with left lower rib fractures. Colonic injuries are not associated with rib fractures. Blunt cardiac injury can happen with sternal fractures.

Question 6.
A patient presents with a large amount of abdominal distention, vomiting, and generalized abdominal pain. On assessment, the emergency nurse notes that no bowel sounds are present. The patient has a history of a temporary colostomy for a ruptured colon 5 years before, a cholecystectomy, and appendectomy. Medical history includes hypothyroidism and hypertension. The emergency nurse realizes that this patient will be prone to all of the following potential complications EXCEPT:
(a) sepsis.
(b) pneumonia.
(c) dehydration.
(d) perforation.
Answer:
(b) pneumonia.

Nursing Process: Analysis/Gastrointestinal 

Rationale: 
Pneumonia would not be a possible complication. The description of this patient in the scenario is that of bowel obstruction. Patients with bowel obstruction will have generalized abdominal pain, vomiting, and abdominal distention. In this case, the large amount of distention would point toward a large bowel obstruction. The past history of the repair for a ruptured colon and the appendectomy could create a situation in which adhesions are present that could cause a bowel obstruction. Complications for this disease process include sepsis, dehydration due to a third spacing that occurs and the vomiting and possible perforation.

Question 7.
Signs and symptoms of acute arterial occlusion include which of the following symptoms?
(a) Pain, pallor, pulselessness, paresthesia, and paralysis
(b) Chest pain, tachycardia, tachypnea, and elevated temperature
(c) Severe pain, blood pressure variation in arms, and peripheral cyanosis
(d) Chest pain, dyspnea, nausea, diaphoresis, and fatigue
Answer:
(a) Pain, pallor, pulselessness, paresthesia, and paralysis

Nursing Process: Assessment/Cardiovascular 

Rationale: 
The signs of acute arterial occlusion are referred as the “5Ps”: Pain, Pallor, Pulselessness, Paresthesia, and Paralysis. Chest pain, tachycardia, tachypnea, and elevated temperature may be seen in pericarditis. Severe pain, blood pressure variation in arm, and peripheral cyanosis are seen in aortic injuries. Chest pain, dyspnea, nausea, diaphoresis, and fatigue are seen in myocardial infarctions.

Question 8.
A patient presents with a narrow-complex tachycardia. Vital signs are as follows:
Blood pressure—110/82 mm Hg 
Pulse—180 beats/minute 
Respirations—20 breaths/minute 
Pulse oximetry—95 % on room air 
Temperature—98.6° F (37° C)

Which of the following initial outcomes will be expected with the successful use of the proper medication to treat this patient?
(a) Third-degree AV block 
(b) Burst of atrial fibrillation 
(c) Ventricular tachycardia 
(d) Period of asystole
Answer:
(d) Period of asystole

Nursing Process: Evaluation/Cardiovascular 

Rationale: 
The drug of choice for stable narrow-complex tachycardia is Adenocard (adenosine). This medication will cause a short period of asystole before conversion to normal sinus rhythm. The other options are not expected outcomes.

Question 9.
Which of the following is the primary goal in the treatment of a patient with acute respiratory distress syndrome (ARDS)?
(a) Treating the underlying condition 
(b) Maintaining nutritional requirements 
(c) Maintaining adequate tissue oxygenation 
(d) Preventing secondary infection
Answer:
(a) Treating the underlying condition 

Nursing Process: Analysis/Respiratory 

Rationale: 
Identifying and treating the underlying condition is the primary goal. If the condition causing acute respiratory distress syndrome (ARDS) is not treated, injury to the lung will continue, preventing adequate tissue oxygenation and predisposing the patient to a secondary infection. Later, the nurse should also provide adequate nutritional support in the form of increased protein and calories and limited carbohydrate intake.

Question 10.
A FAST (Focused Assessment with Sonography for Trauma) examination is performed on a patient involved in a motor vehicle crash. Which of the following statements made by the emergency nurse indicates an understanding of this evaluation tool?
(a) “I heard that this tool is great and has a 90% to 100% accuracy rating for all patients.”
(b) “This is great to use! We will have our answer for sure in a few minutes!”
(c) “This diagnostic tool is so much better for small bowel and stomach injuries.”
(d) “This test only checks for large amounts of blood in the abdomen.”
Answer:
(d) “This test only checks for large amounts of blood in the abdomen.”

Nursing Process: Evaluation/Gastrointestinal 

Rationale: 
The FAST (Focused Assessment with Sonography for Trauma) examination is sensitive for large amounts of blood in the abdomen. If there is less than 400 mL of fluid in the abdomen, it is not usually identified. It is most sensitive (90% to 100% of the time) if there is at least 1,000 mL present in the abdomen. This test does not work as well as the diagnostic peritoneal lavage or the computed tomography (CT) for injuries of the stomach or small bowel. If the FAST examination is negative, it does not mean there are no injuries.

Question 11.
The level of anxiety at which a patient loses their ability to think logically is:
(a) level I: mild.
(b) level II: moderate.
(c) level III: severe.
(d) level IV: panic.
Answer:
(d) level IV: panic.

Nursing Process: Assessment/Psychosocial 

Rationale: 
Level IV anxiety is typified by an inability to solve problems or think logically and obligates the nurse to identify safety plans for the patient and others as the patient may experience changes in their personality. Patients with Level I anxiety are aware of their environmental stimuli and can rationally problem-solve. Level II is associated with a heightened focus on immediate concerns while the patient remains cooperative with care providers. Level III anxiety patients do not engage with the full spectrum of their situation and demonstrate regressive behaviors while often needing repetitive direction.

Question 12. 
Which of the following statements made by the wife of a patient who was an unsuccessful resuscitation attempt would most indicate that her presence during the attempt was a positive experience?
(a) “I wonder if more medicine would have helped?”
(b) “I will never get over seeing the screen show that flat line. ”
(c) “I feel like nothing more could have been done.”
(d) “I wish I had had someone to explain things to me.”
Answer:
(c) “I feel like nothing more could have been done.”

Nursing Process: Evaluation/Psychosocial 

Rationale: 
The Emergency Nurses Association (ENA) as well as other international emergency nurse associations (and national emergency care organizations) support family presence during resuscitation. Family members who are in the room can see all of the things that are being done for their loved one. This is a positive outcome for those who are left behind. It is difficult for them to see the reality of the death but it can help the grieving process to begin. Staff members should always be present when this is done. That staff member’s total responsibility is the family member. Family members should have this support or they should not be allowed into the resuscitation room.

Question 13.
Which of the following is the most critical intervention during the first minutes of ventricular fibrillation?
(a) Advanced airway 
(b) Epinephrine 0.1 mg IV/IO 
(c) Immediate cardiac compressions 
(d) Electrical defibrillation
Answer:
(c) Immediate cardiac compressions 

Nursing Process: Intervention/Cardiovascular 

Rationale: 
CPR performed early can double or triple survival from witnessed sudden cardiac arrest. For every minute that passes between collapse and defibrillation, the chance of survival from a witnessed ventricular fibrillation declines by 7% to 10% per minute if no bystander cardiopulmonary resuscitation is provided. A major emphasis of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) is high-quality chest compressions with minimal interruption and a decreased emphasis on early placement of an advanced airway providers may defer insertion of an advanced airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates return of spontaneous circulation (ROSC). The optimal number of cycles of CPR and shocks required before starting pharmacologic therapy remains unknown; however, epinephrine should be given when IV/IO access is accomplished. Defibrillation should be performed as soon as it can be accomplished and immediate CPR should be performed while waiting to shock.

Question 14.
All of the following would indicate reperfusion after thrombolytic therapy EXCEPT:
(a) relief of chest pain.
(b) onset of dysrhythmia.
(c) ST-segment normalization.
(d) Osborn wave. 
Answer:
(d) Osborn wave. 

Nursing Process: Evaluation/Cardiovascular 

Rationale: 
An Osborn wave, also called a J wave, is an extra positive deflection between the QRS and the ST segment that accompanies hypothermia. It has nothing to do with cardiac reperfusion status post thrombolytic administration. Patients who have a successful reperfu-sion will have relief of chest pain and ST-segment nor-malization. The most common reperfusion dysrhythmia is accelerated idioventricular.
 
Question 15.
Which of the following statements made by a patient being discharged with a diagnosis of Raynaud’s phenomenon would indicate that the discharge instructions were understood?
(a) “I will wear gloves to keep warm and work hard on stopping smoking.”
(b) “I will keep my arm elevated on a pillow and apply ice to my hand.”
(c) “I have an elastic bandage at home that I can wear when I am on the computer.”
(d) “I will drink plenty of fluids and take aspirin for the pain.”
(a) “I will wear gloves to keep warm and work hard on stopping smoking.”
Answer:
(a) “I will wear gloves to keep warm and work hard on stopping smoking.”

Nursing Process: Evaluation/Cardiovascular 

Rationale: 
Raynaud’s phenomenon is a circulatory disease of the arteries that severely reduces blood flow as the result of episodic intense vasospasm of the digits in response to extreme cold, emotional stress, and/or smoking. Treatment is aimed at decreasing pain and vasospastic events. The patient should be advised to keep warm, wear gloves, not smoke, and avoid cold medicines and diet pills because of their vasoconstrictive effects. Elevating the arm and applying ice would worsen the vasoconstriction. Wrist splints or applying an elastic bandage would not help and may increase vaso-constriction. Fluids and aspirin would not help.

Question 16.
A 14-month-old infant with vomiting and diarrhea has been prescribed a fluid bolus for treatment of dehydration. The child weighs 20 pounds. Which of the following is the correct bolus amount?
(a) 180 mL
(b) 200 mL    
(c) 400 mL
(d) 900 mL
Answer:
(a) 180 mL

Nursing Process: Intervention/Gastrointestinal 

Rationale: 
Fluid bolus rehydration for infants and children is based on 20 mL/kg of body weight. For this patient weighing 20 pounds, the first step in the mathematical equation is to change the pounds to kilograms. This is the most common error in calculations. Therefore, 20 pounds is equal to 9 kg (20 divided by 2.2), and 9 kg X 20 mL = 180 mL bolus. If the pounds are not changed to kilograms, then the incorrect mathematical outcome would be 400 mL. If an incorrect formula is used and 10 mL/kg is considered to be correct, then the outcome utilizing pounds is 200 mL or 900 mL if the correct conversion is made to kilograms but the incorrect formula is used.

Question 17.
During a manic episode, a patient with bipolar disorder may:
(a) present withdrawn and depressed.
(b) present unkempt with poor hygiene.
(c) display poor social judgment.
(d) refuse to answer questions.
Answer:
(c) display poor social judgment.

Nursing Process: Assessment/Psychosocial 

Rationale: 
During a manic phase, the patient with bipolar disorder often has poor social judgment, which can manifest as sexual inappropriateness, become hypersocial, with rapid, verbose speech without allowing opportunity for reciprocal communication, and/or display grandiosity of thought and ideas. The manic phase is the opposite of the depressed phase, which may manifest with social withdrawal. The manic patient is more likely to display flamboyant personal style and dress rather than be unkempt. Patients in a manic episode will usually be more than willing to answer questions often providing long and rambling explanations to questions. It will be difficult to keep them on task and to elicit appropriate answers from them.

Question 18.
Which level trauma center must have a trauma surgeon, trauma director, operating suite, and in-house operating room staff on duty 24 hours per day?
(a) Level I trauma center only 
(b) Level I, II, and III trauma centers 
(c) Level I and II trauma centers 
(d) Level IV trauma center
Answer:
(c) Level I and II trauma centers 

Cognitive Level: Recall/Professional Issues 

Rationale: 
Level I and Level II trauma centers must have a trauma surgeon, trauma director, and staffed operating room available around the clock. Level III trauma centers are excused from the staffed operating room requirement. Level IV trauma centers are excused from all the above requirements.

Question 19.
Which of the following is a manager allowed to do in response to a collective bargaining initiative?
(a) Prevent employees from engaging in recruiting activities during nonworking hours.
(b) Prevent employees from participating in informal union activities in patient care areas.
(c) Withhold desirable assignments from those nurses who are union organizers.
(d) Provide special considerations to discourage employees from joining the union.
Answer:
(b) Prevent employees from participating in informal union activities in patient care areas.

Cognitive Level: Application/Professional Issues 

Rationale: 
Federal laws allow management to prevent employees from engaging in collective bargaining in patient care areas. The same laws prohibit managers from preventing union activities during nonworking hours, from withholding desirable assignments from staff engaging in union activities, and from providing special favors to discourage union activity or membership.

Question 20.
A patient arrives in the emergency department with the following signs and symptoms: worsening dyspnea, tachypnea, cough, edema, fatigue, and distended neck veins. The emergency nurse suspects which of the following as a primary diagnosis?
(a) Pulmonary embolism 
(b) Heart failure 
(c) Cardiac tamponade 
(d) Tension pneumothorax
Answer:
(b) Heart failure 

Nursing Process: Assessment/Cardiovascular 

Rationale: 
Heart failure is the result of structural and functional impairment of ventricular filling or ejection of blood. Most patients have impairment of myocardial function, ranging from normal ventricular size and function to marked dilation and reduced function. Worsening dyspnea is a cardinal symptom of heart failure and dyspnea at rest is often mentioned by patients. The symptoms stated in the question reflect pulmonary congestion. Pulmonary embolism occurs with occlusion of pulmonary blood vessels and the patient may have dyspnea, but pleuritic chest pain, pleural friction rub, and signs and symptoms of a deep vein thrombosis would also be expected; edema would not occur with a pulmonary embolism. 

Cardiac tamponade is the collection of blood in the pericardial sac, which limits ventricular filling and thus decreases cardiac output; signs and symptoms would include chest pain and Beck’s triad: dis-tended neck veins (JVD), distant heart sounds (muffled), and hypotension. Tension pneumothorax occurs when air enters the pleural space during inspiration and is unable to escape during exhalation. This leads to a rising intra-thoracic pressure, which compresses the lungs, heart, and great vessels in the chest. It is preceded by blunt or penetrating trauma and causes severe respiratory distress and absent breath sounds on the affected side.

Question 21.
Which of the following would the emergency nurse anticipate for a patient with an aortic dissection?
(a) Emergent surgery 
(b) Chest tube insertion 
(c) Immediate intubation 
(d) Pericardial decompression
Answer:
(a) Emergent surgery 

Nursing Process: Intervention/Cardiovascular 

Rationale: 
Definitive treatment of an acute aortic dissection consists of surgical repair of the rupture. Chest tube placement is indicated for pneumothoraces or hemothorax. The priority is to move the patient to definitive care; intubation can be accomplished in the operating room. Pericardial decompression is indicated for pericardial tamponade.

Question 22.
A patient with a previous medical history of stroke is brought to the emergency department with altered mental status. The patient’s baseline mental status is alert and oriented to person, place, time, and event; however, at this time, the patient is responsive to painful stimuli only. Examination reveals hot, moist skin with a tympanic temperature of 102.2° F (39° C), adventitious lung sounds, and tachycardia. The emergency nurse suspects which of the following as a possible reason for these signs?
(a) Congestive heart failure 
(b) Meningitis 
(c) Aspiration pneumonia 
(d) Stroke
Answer:
(c) Aspiration pneumonia 

Nursing Process: Assessment/Respiratory 

Rationale: 
Because a patient who has had a stroke may be at high risk for aspiration, the combination of warm, moist skin, and adventitious lung sounds most likely results from aspiration pneumonia. An acute onset of altered mental status may indicate a new stroke; however, the presence of a fever suggests an infectious process, ruling out congestive heart failure and a stroke. The adventitious lung sounds do not correlate with meningitis.

Question 23.
The Joint Commission in 2018 released a Quick Safety alert on “identifying Human Trafficking Victims” and pinpointed several red flags of a potential victim. All of the following would be examples of human trafficking victims EXCEPT:
(a) acting fearful, anxious, depressed, submissive, tense, nervous or paranoid, and avoiding eye contact.
(b) requesting additional follow-up treatment at a separate appointment in order to see another provider.
(c) showing reluctance or refusing to change into a gown and/or to cooperate with the physical examination.
(d) exhibiting behavior or demeanor not in alignment with injury or complaint (i.e., acts like it is “no big deal”).
Answer:
(b) requesting additional follow-up treatment at a separate appointment in order to see another provider.

Cognitive Level: Recall/Professional Issues 

Rationale: 
Option B is the exception to behaviors related to human trafficking victims because the patient will not request additional follow-up or treatment; the patient will most likely refuse any follow-up if provided. Each of the other answers describe behaviors that may indicate the patient is a victim of trafficking.

Question 24.
An elderly patient with stroke-like symptoms has an active DNR (Do Not Resuscitate) order. In caring for this patient, the understanding would be which of the following options?
(a) Should not initiate labs or an IV line as the patient does not want further treatment.
(b) May not provide care for this patient until family arrives and gives consent.
(c) An intravenous line may be established, but no medications should be given.
(d) Should initiate care for this patient’s stroke symptoms regardless of the DNR wishes.
Answer:
(d) Should initiate care for this patient’s stroke symptoms regardless of the DNR wishes.

Cognitive Level: Analysis/Professional Issues 

Rationale: 
The DNR order is meant to inform healthcare providers that the patient does not want lifesaving techniques performed at the time of cardiac/ respiratory arrest. It does not allow the nurse to assume the patient does not want care for his current condition. Care should be provided to this patient following the standards of care for a stroke patient.

Question 25.
A patient presents to the emergency department with chief complaint of feeling weak and generalized fatigue. The patient is diaphoretic with cool skin. He states persistent nausea without vomiting. Vital signs are as follows:
Blood pressure—92/64 mm Hg 
Pulse—122 beats/minute 
Respirations—32 breaths/minute 
Pulse oximetry—91 % on room air 
Temperature—98.8° F (37.1° C)

Past history reveals hypertension, chronic bronchitis, recent history of fracture of the left 11th to 12th ribs, and hypercholesteremia. Which of the following diagnoses would the emergency nurse suspect?
(a) Pneumonia 
(b) Pancreatitis 
(c) Splenic injury 
(d) Lacerated liver
Answer:
(c) Splenic injury 

Nursing Process: Analysis/Gastrointestinal 

Rationale: 
This patient’s recent fall has probably contributed to the development of a splenic injury. Fractures of the left lower ribs can lead to spleen lacerations that become evident several days after initial injury. Fractures of the lower right ribs are prone to causing liver injuries. This patient is not demonstrating any manifestations that should make the nurse consider pneumonia or pancreatitis. A fever and usually a cough should be present with pneumonia, and pancreatitis would present with severe pain to left mid-quadrant.

Question 26.
The psychiatric condition with the highest mortality rate is:
(a) anorexia nervosa.
(b) bipolar disorder.
(c) dementia.
(d) psychotic depression.
Answer:
(a) anorexia nervosa.

Nursing Process: Analysis/Psychosocial 

Rationale: 
Anorexia nervosa has the highest mortality rate due to metabolic complications and concomitant risk of suicidal ideation. Although all other mentioned diagnoses have mortality risks, anorexia has the highest risk of all psychiatric diagnoses.

Question 27.
All of the following medications could be utilized to treat pancreatitis EXCEPT:
(a) dicyclomine (Bentyl).
(b) fentanyl (Sublimaze).
(c) octreotide (Sandostatin).
(d) famotidine (Pepcid).
Answer:
(c) octreotide (Sandostatin).

Nursing Process: Intervention/Gastrointestinal 

Rationale: 
Octreotide (Sandostatin) is used to treat esophageal varices associated with liver disease. Dicyclomine (Bentyl) is an anticholinergic medication that hinders the release of pancreatic secretions by preventing nerve impulses from stimulating the cells. Fentanyl (Sublimaze) can be used to treat the pain associated with pancreatitis. Histamine Hrinhibitors such as famotidine (Pepcid) prevents histamine release that increases the pancreatic secretions.

Question 28.
A patient is seen in the emergency department following a motor vehicle crash. He is diagnosed with a perforated stomach, a pelvic fracture, upper left arm fracture, and a mild closed head injury. Which of the following complications would the emergency nurse understand to be the highest probability to occur for this patient due to the injuries sustained?
(a) Cardiogenic shock 
(b) Pulmonary edema 
(c) Peritonitis 
(d) Paralysis
Answer:
(c) Peritonitis 

Nursing Process: Analysis/Gastrointestinal 

Rationale: 
When the stomach is torn or perforated, hydrochloric acid and enzymes escape which then causes peritonitis. There is a very high probability that peritonitis will follow for this patient. The patient is at much higher risk for hypovolemic shock rather than cardiogenic. Pulmonary edema and paralysis would not occur in this scenario. There is no chest or spinal cord injury.

Question 29.
Research that aims to examine the feelings and perceptions of emergency nurses working with battered female patients is which of the following types of study?
(a) Qualitative
(b) Quasi-scientific 
(c) Quantitative 
(d) Experimental
Answer:
(a) Qualitative

Cognitive Level: Application/Professional Issues 

Rationale: 
A study that examines thoughts and perceptions is one that lends itself to a qualitative design. Qualitative research is concerned with understanding human beings and the nature of their transactions with themselves and their surroundings. The process is not quasi-scientific, rather a well-accepted mode of rigorous, systematic inquiry used in the social sciences. Quantitative research methods analyze data statistically while striving for precision and control over external variables. Experimental research involves doing something to some of the subjects and not doing something to others; in it, subjects are randomly assigned to either group.

Question 30.
An 11-month-old child is brought to the emergency department by his parents. His parents tell the emergency nurse he has been coughing and has had a runny
nose for 1 day. He has a red rash on his face, a rectal temperature of 102.5° F (39.2° C), and bluish-white spots on his buccal mucosa. Which of the following conditions are these symptoms associated with?
(a) Mumps 
(b) Measles (Rubeola)
(c) Allergic reaction 
(d) Varicella (chicken pox)
Answer:
(b) Measles (Rubeola)

Nursing Process: Assessment/Communicable 

Rationale: 
The CDC immunization schedule for children is a first dose at age 12 to 15 months, followed by a second dose between ages 4 to 6 years, before the child enters school. An 11-month-old would not have had the vaccine. Koplik spots, small, red specks with a bluish-white center on the buccal mucosa, are a diagnostic lesion of measles. They appear approximately 2 days before the rash and disappear within 48 hours after the rash. There is a difference between rubella (also known as 3 day measles) and rubeola (commonly known as measles). Mumps cause glandular enlargement of the parotid and salivary glands. There is no rash associated with mumps. In postpuberty males, the testes may be involved, producing orchitis and a risk of infertility. An allergic reaction may produce urticaria, hives, and a dis-seminated rash. The characteristic symptom of varicella is a vesicular rash that begins on the trunk and becomes generalized.

Question 31.
Sickle cell crisis is associated with a number of precipitants. Which of the following is NOT one of these precipitants?
(a) Cold ambient temperature 
(b) Infection
(c) Metabolic or respiratory alkalosis 
(d) High altitude
Answer:
(c) Metabolic or respiratory alkalosis 

Nursing Process: Assessment/Medical 

Rationale: 
A state of acidosis, not alkalosis, can precipitate a sickle cell crisis. Acidosis results in a shift to the right on the oxyhemoglobin dissociation curve (Bohr effect), causing hemoglobin to desaturate (release oxygen) more readily. Cold ambient temperature, infection, and high altitude are well-documented triggers of sickle cell crisis, and patients with this disease are instructed to take appropriate actions to avoid exposure to these triggers.

Question 32.
Objective assessment of an acute aortic dissection would include which of the following?
(a) Manual blood pressure taken in both arms 
(b) Inspection for petechial rash to extremities 
(c) Inspection for extremity edema, anasarca, and ascites
(d) Auscultation of heart sounds for prominent apical pulse/S3 and S4
Answer:
(a) Manual blood pressure taken in both arms 

Nursing Process: Assessment/Cardiovascular 

Rationale: 
Manual blood pressures taken in both arms would be the correct objective assessment parameter. The primary event in an aortic dissection is a tear in the aortic intima, which allows blood to pass into the aortic media, thereby creating a false lumen; pressure within this false channel can compress the true aortic lumen and reduce blood flow. A considerable variation greater than 20 mm Hg systolic may be seen when comparing the blood pressure in the arms with this diagnosis. Inspection for petechiae related to microemboli is performed for a suspected acute arterial occlusion. Edema of the extremities, anasarca (generalized swelling), or ascites would be assessed for heart failure and cardiogenic pulmonary edema. Prominent apical pulse, S3 or S4 are found in hypertensive crises cases.

Question 33.
A patient arrives with a gunshot wound to the left chest. The patient is alert, complaining of pain and difficulty breathing. Objective data include hypotension, muffled heart sounds, jugular vein distention (JVD), tachycardia, tachypnea, and an open wound to the left chest. Oxygen via a non-rebreather and two large-bore intravenous catheters have been placed. Vital signs on arrival were as follows:
Blood pressure—80/50 mm Hg 
Pulse—125 beats/minute 
Respirations—32 breaths/minute 
Pulse oximetry—80% on room air 
Temperature—98.6° F (37° C)

Which of the following should the emergency nurse anticipate to prepare for next?
(a) Assist with a resuscitative thoracotomy.
(b) Prepare for massive blood transfusion.
(c) Assist with a pericardiocentesis.
(d) Prepare for aggressive ventilatory support.
Answer:
(c) Assist with a pericardiocentesis.

Nursing Process: Intervention/Cardiovascular 

Rationale: 
Beck’s triad, which consists of hypotension, muffled heart sounds, and jugular vein distension, along with tachycardia, dyspnea, cyanosis and a history of penetrating trauma, are signs of a pericardial tamponade, a collection of blood in the pericardial sac. As blood accumulates in the noncompliant pericardial sac, it exerts pressure on the heart, inhibiting ventricular filling and, therefore, cardiac output. A pericardiocentesis will aspirate the blood out of the sac and relieve the pressure on the heart. A resuscitative thoracotomy is indicated with a traumatic cardiac arrest. Massive blood transfusion is not indicated at this point. Ventilatory support may be necessary when the patient goes for surgical repair, but the first priority is relieving pressure on the heart to improve cardiac output.

Question 34.
A nonresponsive 64-year-old patient has the following findings in the emergency department: blood glucose 340 mg/dL, serum osmolality 320 mOsm/kg, and pH 7.2. The patient is taking deep, gasping respirations. The emergency nurse should suspect which of the following disease processes?
(a) Hyperthyroid crisis (Storm)
(b) Hyperosmolar hyperglycemic syndrome (HHS)
(c) Syndrome of inappropriate antidiuretic hormone (SIADH)
(d) Diabetic ketoacidosis (DKA)
Answer:
(d) Diabetic ketoacidosis (DKA)

Nursing Process: Assessment/Medical 

Rationale: 
Most hyperglycemic emergencies are due to diabetic ketoacidosis (DKA). A decrease in available insulin increases the blood glucose level because it cannot be transported into cells. To meet the body’s energy needs, the liver metabolizes fatty acids which break down into ketone bodies. Dehydration, electrolyte losses, acidosis, and ketonuria ensues. Kussmaul respirations (deep, rapid breathing) are a compensatory mechanism to buffer the acidosis by reducing serum carbon dioxide levels. Patients in thyroid storm will appear in a hyperdynamic state, with elevated heart rate, blood pressure, and temperature. Metabolic changes are not common. Hyperosmolar hyperglycemic syndrome (HHS) is characterized by blood glucose levels more than 600 mg/dL and an absence of acidosis. Syndrome of inappropriate antidiuretic syndrome, due to oversecretion of the antidiuretic hormone, is characterized by decreased urinary output and sodium levels, lethargy, and confusion.

Question 35.
A mother brings her 3-year-old to the emergency department because of blood in the child’s underwear. The examination by the sexual assault nurse examiner (SANE nurse) reveals sexual assault and felonious penetration. The mother wants to leave. Which action should the nurse take?
(a) No action is necessary because the mother is the child’s legal guardian and her decisions are final.
(b) Immediately report the findings to Child Protective Services and the police.
(c) Encourage the mother to reconsider her decision and refer her to a child psychologist.
(d) Have the emergency department physician talk to the mother and try to persuade her to stay.
Answer:
(b) Immediately report the findings to Child Protective Services and the police.

Cognitive Level: Application/Professional Issues 

Rationale: 
The nurse has a duty of care to the patient and to the public and must report the crime to the authorities. Regardless of the mother’s wishes, the child has been harmed and a report to the authorities is necessary. Even though the emergency physician may talk to the mother and the mother may be encouraged to reconsider her wishes, the fact remains that the crime must be reported and evidence must be collected.

Question 36.
A 2-year-old female child is brought to the emergency department with a distended abdomen and vomiting. Assessment reveals a lethargic toddler who does not cry when examined. The child’s skin is cool and slightly diaphoretic. No bowel sounds are heard. Breath sounds are clear to auscultation. Vital signs are as follows:
Blood pressure—76/42 mm Hg 
Pulse—164 beats/minute 
Respirations—44 breaths/minute 
Pulse oximetry—84% on room air 
Temperature—99.8° F (37.6° C) rectal

A KUB (kidney, ureter, bladder) radiograph is obtained that shows air-fluid levels. Which of the following would be the highest priority for this child?
(a) Oxygen by mask or flow by 
(b) Intravenous line 
(c) Fluid administration 
(d) Urinary catheter
Answer:
(a) Oxygen by mask or flow by 

Nursing Process: Intervention/Gastrointestinal 

Rationale: 
This child is in distress, most likely with a bowel obstruction, and needs to have oxygen started immediately. She obviously needs an intravenous line and fluid administration, but these will take time and, therefore, the fastest intervention that can be done is to start high-flow oxygen. The urinary catheter is also important but again will take time and can be done after the airway is maintained and the fluid bolus is started.

Question 37.
Potential nonpsychiatric causes of acute agitation and behavior changes include all of the following EXCEPT.
(a) hypoxia.
(b) thyroid disorders.
(c) stroke.
(d) dementia.
Answer:
(d) dementia.

Nursing Process: Analysis/Psychosocial 

Rationale: 
Dementia can result in acute agitation related to confusion and amplified sensory stimulation in the emergency department but is not the cause of the initial presenting symptom. All the other conditions are considerations for medical causes of agitation that may be part of the decision-making before a patient is “medically cleared” for psychiatric treatment. Both hypothyroidism and hyperthyroidism are causes of behavioral issues that can appear to be psychiatric in nature.

Question 38.
A patient arrives in the emergency department with bright red, bloody emesis. He is vomiting on arrival and continues as he is placed into a room. He is pale and diaphoretic with cold extremities. Vital signs are as follows:
Blood pressure—82/46 mm Hg 
Pulse—146 beats/minute 
Respirations—36 breaths/minute 
Pulse oximetry—89% on room air 
Temperature—99.4° F (37.4° C)

The team starts two large-bore intravenous lines and crystalloids are begun at a rapid rate. All of the following would be anticipated by the emergency nurse EXCEPT:
(a) type and screen.
(b) gastric tube placement.
(c) contact endoscopy.
(d) cardiac monitoring.
Answer:
(a) type and screen.

Nursing Process: Intervention/Gastrointestinal 

Rationale: 
This patient is actively bleeding. A type and crossmatch is needed, not a type and screen. Blood needs to be set up immediately and the patient may need type-specific or universal donor (0 negative) blood products before the crossmatch can be completed. Gastric tube placement, contacting the endoscopy department for a potential emergent procedure, and cardiac monitoring are all important treatment interventions for this patient. The patient; needs close monitoring of vital signs and cardiac rhythms.

Question 39.

The emergency nurse recognizes the above rhythm as:
(a) first-degree heart block.
(b) second-degree heart block, type I.
(c) second-degree heart block, type II.
(d) third-degree heart block.
Answer:
(c) second-degree heart block, type II.

Nursing Process: Assessment/Cardiovascular 

Rationale: 
Second-degree heart block, type II, is characterized by a constant PR interval that is followed by a non-conducted P wave. First-degree heart block is the most common conduction disturbance and is characterized by a PR interval that is greater than 0.20 seconds and rarely requires treatment. Type I second-degree heart block (Mobitz I or Wenckebach) is slower and slower impulse conduction through the AV node and is seen as a gradual prolongation of the PR interval until one depolarization from the atria is completely blocked. Third-degree heart block results from injury to the cardiac conduction system so that no impulses are conducted from the atria to the ventricles; the atrial contractions are faster and independent of the slower-beating ventricles.

Question 40.
Which of the following is the most common and concerning electrolyte imbalance associated with digoxin toxicity?
(a) Hyponatremia 
(b) Hypercalcemia 
(c) Hypomagnesemia 
(d) Hyperkalemia
Answer:
(d) Hyperkalemia

Nursing Process: Analysis/Cardiovascular 

Rationale: 
The most common and concerning electrolyte abnormality associated with acute digoxin toxicity is hyperkalemia that occurs due to the binding affinity for digoxin on the Na/K pump site on each cell. Hyponatremia, hypercalcemia, and hypomagnesemia are not electrolyte disturbances that occur with digoxin toxicity.

Question 41.
After teaching the patient with asthma about inhalers, which of the following statements indicates the need for further instruction?
(a) “I should hold the inhaler upright and shake it well.”
(b) “I should hold my breath for 5 to 10 seconds after each puff. ”
(c) “I should hold the inhaler in my mouth with a good seal.”
(d) “I should hold my head back and forcefully exhale.”
Answer:
(d) “I should hold my head back and forcefully exhale.”

Nursing Process: Evaluation/Respiratory 

Rationale: 
A forced exhalation is not recommended during inhaler use because coughing, small-airway closure, and air trapping may result. The correct technique for using an inhaler is as follows: the inhaler must be held upright and shook to ensure it is mixed thoroughly before administration. After inhalation of the medication, the patient should then hold his/her breath for 5 to 10 seconds to allow the medication to reach as far as possible into the lungs. If the patient has difficulty with this technique, a spacer device may be added to the inhaler. A good seal should also be part of the process.

Question 42.
Which of the following is the most likely intervention for a patient with a suspected diaphragmatic rupture?
(a) Needle thoracostomy 
(b) Chest tube insertion 
(c) Preparation for surgery 
(d) Transfer to unit for observation
Answer:
(c) Preparation for surgery 

Nursing Process: Intervention/Respiratory

Rationale: 
Preparing a patient for surgical repair is the most important intervention for a ruptured diaphragm. Needle thoracostomy and chest tube insertion are contra-indicated in this patient because of the risk of puncturing the bowel and releasing its contents into the chest cavity. The potential for serious complications contraindicates transfer for observation. Intravenous (IV) fluids may become necessary if the bowel compresses large vessels, causing a decrease in preload.

Question 43.
Which of the following statements would suggest that the patient diagnosed with mononucleosis understands their condition?
(a) “I can share eating utensils with others as long as I don’t have a fever.”
(b) “I need to avoid strenuous activity and contact sports for a month.”
(c) “A vaccination would have prevented me from contracting this.”
(d) “This is an inherited disease and there is nothing
Answer:
(b) “I need to avoid strenuous activity and contact sports for a month.”

Nursing Process: Evaluation/Medical 

Rationale: 
Splenomegaly occurs frequently in mononucleosis. Because of the risk of injury to an enlarged spleen, strenuous activity and contact sports should be avoided for at least 4 weeks. The virus is shared primarily via saliva and oropharyngeal route. Sharing eating utensils or food, kissing, and similar actions should be avoided during the incubation period of up to 60 days. There is no vaccine to prevent mononucleosis. It is a communicable virus, not a hereditary disorder.

Question 44.
When caring for a patient who is acutely agitated and presenting a risk to self and others, which of the following is an appropriate intervention?
(a) Administer enough medication to get them to sleep.
(b) Place them in a seclusion room with a sitter or status checks every 15 minutes.
(c) Immediately implement four-point leather restraints.
(d) Begin with the least restrictive means necessary to keep them and others safe.
Answer:
(d) Begin with the least restrictive means necessary to keep them and others safe.

Nursing Process: Intervention/Psychosocial 

Rationale: 
Keeping the patient and others safe during a period of crisis is the priority and should be achieved using the least restrictive yet effective means. This may include a combination of medications and changes to the physical environment and their mobility, but it must be implemented in a measured fashion that may involve escalating restriction and medication modalities with the goal of being effective, not excessive and never punitive or because it is just too hard to care for them short of sedation until asleep.

Question 45.
“The protective privilege ends where the public peril begins” indicates the duty of the emergency nurse when a patient threatens another person with bodily injury or harm. What does the quoted statement mean?
(a) Confidentiality between patient and nurse does not relieve staff of the duty to warn the threatened person and authorities.
(b) Confidentiality between nurse and patient is as sacred as the attorney-client privilege and is never broken.
(c) The emergency nurse must weigh the seriousness of the threat before breaking the confidentiality of that patient.
(d) Warning the patient not to commit a felony covers the emergency nurse as duty to warn and is sufficient.
Answer:
(a) Confidentiality between patient and nurse does not relieve staff of the duty to warn the threatened person and authorities.

Cognitive Level: Application/Professional Issues 

Rationale: 
Confidentiality between patient and nurse (or physician) should be breached to alleviate a threat to another person. Medical personnel have a duty to warn the intended victim (if known) and the authorities. Warning the patient not to commit a felony or weighing the seriousness of the threat is not sufficient grounds for relief from the duty to warn.

Question 46.
An elderly patient has decided to discontinue treatment. It would be recognized that the patient is competent to make this decision and support the decision based on which of the following ethical principles?
(a) Justice 
(b) Fidelity 
(c) Autonomy 
(d) Confidentiality
Answer:
(c) Autonomy 

Cognitive Level: Application/Professional Issues 

Rationale: 
A patient is competent to make his/her own decisions and therefore entitled by the ethical principle of autonomy, the right to make decisions regarding a patient’s own body. Autonomy is the right of the patient to retain control over his or her body. Actions that attempt to persuade or coerce the patient into making a choice are violations of this principle, whether the medical provider believes these choices are in that patient’s best interest. Beneficence refers to doing all that can be done to benefit the patient in each situation. All recommended procedures and treatments should consider each patient's individual circumstances. 

Emergency staff members should be trained in the most current and best practices and must recognize that what is good for one patient will not necessarily benefit another. Nonmaleficence means “to do no harm.” This means that we must also consider whether other people or society could be harmed by a decision made, even if it is made for the benefit of an individual patient. Justice recognizes that there should be fairness in all our decisions, including equal distribution of scarce resources and new treatments.

Question 47.
A patient is being seen in the emergency department with Herpes Zoster. The appropriate staff member to care for this patient would be a nurse who has never had:
(a) pertussis.
(b) chickenpox.
(c) mumps.
(d) measles.
Answer:
(b) chickenpox.

Nursing Process: Analysis/Communicable 

Rationale: 
Herpes Zoster is caused by the reactivation of a dormant varicella (chickenpox) virus. Vesicular lesions develop along a nerve dermatome and contain the live virus. It is contagious to unvaccinated or susceptible hosts. A person who has not had chickenpox may be susceptible to the virus and become ill. Pertussis is caused by the Bordetella pertussis organism. The measles and mumps viruses are not harbored in the body after the infection clears.

Question 48.
Which of the following is NOT a component of the transfer system between facilities?
(a) Communications with the receiving hospital 
(b) Following your hospital’s policies and procedures 
(c) Available transportation resources in the community
(d) Cost of the transfer to the appropriate location
Answer:
(d) Cost of the transfer to the appropriate location

Cognitive Level: Recall/Professional Issues 

Rationale: 
The components of a transfer system are communications, transport resources, and policies and procedures. Although financial issues may influence where and how the patient is transferred, it is not a component of the transfer itself.

Question 49.
An 86-year-old patient is being prepared for surgery. Which of the following approaches best ensures he will understand the risks and benefits?
(a) Give him enough time to process the information.
(b) Ask family members to make these decisions.
(c) Ask patient to respond immediately so he does not forget.
(d) Give the patient reading material to review postoperatively.
Answer:
(a) Give him enough time to process the information.

Cognitive Level: Application/Professional Issues 

Rationale: 
Allowing time for the information to be processed is necessary because the aging process affects the speed with which cognitive and motor processes are performed. This does not mean that the activities cannot be performed, but rather that they take longer. Family members should not make these decisions unless it is a situation in which the patient cannot capably process the information and make an informed decision. Reading material postoperatively will not assist in making this decision preoperatively.

Question 50.
Disseminated Intravascular Coagulation (DIC) is characterized by all of the following EXCEPT:
(a) microvascular clots.
(b) increased clotting factors.
(c) decreased platelets.
(d) impaired hemostasis.
Answer:
(b) increased clotting factors.

Nursing Process: Assessment/Medical 

Rationale: 
In Disseminated Intravascular Coagulopathy (DIC), both thrombosis and fibrin degradation occur simultaneously, leading to widespread bleeding along with abnormal clotting in the microcirculation. DIC involves inappropriate and accelerated activation of the coagulation cascade manifested by impaired hemostasis, and a depletion of platelets and clotting factors.

Question 51.
Which of the following is the major cause of anaphylaxis?
(a) Food products 
(b) Latex 
(c) Insect stings 
(d) Exercise
Answer:
(a) Food products 

Nursing Process: Analysis/Medical

Rationale: 
Food is implicated in the largest percentage of anaphylactic episodes, causing approximately 13% to 65% of all episodes. Latex is the cause of between 7% and 9% of anaphylactic reactions and has been steadily decreasing with the use of latex-free products, especially in the hospital setting. Insect stings account for 1 % to 7% of episodes. Exercise-induced anaphylaxis is rare, occurring in less than 1 % of the population.

Question 52.
Which of the following would be the proper lead placement to definitively diagnosis a right ventricular infarct?
(a) Fourth intercostal space left sternal border 
(b) Fifth intercostal space right midclavicular line 
(c) Fifth intercostal space posterior axillary line 
(d) Fourth intercostal space right sternal border
Answer:
(b) Fifth intercostal space right midclavicular line 

Nursing Process: Analysis/Cardiovascular 

Rationale: 
A right-sided electrocardiogram (ECG) is performed when concern is present for a right ventricular infarct. V4R to V6R are the leads that will show the ST-segment elevation with V4R being the best. The lead placement for V4R is in the fifth intercostal space at the right midclavicular line. The left side is mimicked on the right side of the chest. Lead placement in the fourth intercostal space at the left sternal border and at the right sternal border would be proper placement for V1 and V2. A lead placed at the fifth intercostal space posterior axillary line would be correct for the posterior lead, V7.

Question 53.
Which of the following findings indicate that a chest tube is NOT effective in the management of a pneumothorax?
(a) Patient resting, pulse oximetry 96% on 2 L/nasal cannula
(b) Breath sounds equal bilaterally, equal chest excursion
(c) Patient anxious, respirations 36 breaths/minute 
(d) Trachea midline, jugular veins not distended
Answer:
(c) Patient anxious, respirations 36 breaths/minute 

Nursing Process: Evaluation/Respiratory 

Rationale: 
After chest tube insertion, the patient should be calm. A patient who is anxious with rapid respirations is showing signs of respiratory distress. If the chest tube is effective, respirations and pulse oximetry reading should be within normal limits. Breath sounds should be heard in all lobes bilaterally with equal excursion of chest. The trachea should be midline without jugular vein distention.

Question 54.
Which of the following would indicate successful use of thrombolytic therapy?
(a) T-wave inversion 
(b) Decreased ST segment 
(c) Prolonged QT intervals 
(d) Pathologic Q waves
Answer:
(b) Decreased ST segment 

Nursing Process: Evaluation/Cardiovascular 

Rationale: 
Thrombolytic therapy should open closed coronary arteries and reperfuse the heart. Reperfusion would be indicated by ST segments falling back to normal levels. Elevated ST segments indicate injury to the heart muscle. T-wave inversion would demonstrate ischemia. Prolonged QT intervals are a negative finding and can be a forerunner of torsade de pointes. Pathologic Q waves are indicative of necrosis in the heart wall.

Question 55.
A patient arrives in the emergency department with a potential anaphylactic reaction after eating peanuts. The patient has edematous lips, urticaria, and inspiratory stridor. Vital signs are as follows:
Blood pressure—86/60 mm Hg 
Heart rate—116 beats/minute 
Respirations—24 breaths/minute 
Pulse oximetry—94% on room air 
Temperature—98.4° F (36.8° C)

After administering epinephrine (Adrenaline), the nurse can anticipate an order for which of the following types of medication?
(a) Corticosteroid 
(b) Beta-blocker 
(c) Histamine-2 blocker 
(d) Antibiotic
Answer:
(c) Histamine-2 blocker 

Nursing Process: Intervention/Medical 

Rationale: 
Studies have shown the combination of an H,-blocker such as diphenhydramine (Benadryl) and an H2-blocker such as famotidine (Pepcid) to be superior to an Hrblocker alone in relieving the histamine-mediated symptoms of anaphylaxis. Corticosteroids have no immediate effect on mitigating anaphylaxis. Beta-blockers may increase the risk of anaphylaxis and inhibit the therapeutic effect of epinephrine in treating anaphylaxis. There is no value to administration of antibiotics in treating anaphylaxis because it is not an infectious process.

Question 56.
Priority interventions for a patient with acute adrenal insufficiency (Addison’s disease) include all of the following EXCEPT:
(a) administration of intravenous (IV) antibiotics.
(b) rapid infusion of a crystalloid solution.
(c) continuous vital sign monitoring.
(d) administration of intravenous (IV) hydrocortisone (Solu-Cortef).
Answer:
(a) administration of intravenous (IV) antibiotics.

Nursing Process: Intervention/Medical 

Rationale: 
Adrenal insufficiency is an endocrine disorder and does not require antibiotic therapy unless there is evidence of an underlying infection. It is not a priority intervention. Hypovolemic shock is a life-threatening complication of acute adrenal insufficiency and requires aggressive fluid resuscitation. Additional priority interventions include administration of exogenous corticoids such as hydrocortisone (Solu-Cortef) or dexamethasone (Decadron). Vital signs should be continually monitored during the initial treatment phase.

Question 57.
A patient being discharged from the emergency department after treatment for hemophilia demonstrates understanding of his condition with which of the following statements?
(a) “I can tell the gang that I can play touch football next weekend.”
(b) “If I need to I can take aspirin for my pain.”
(c) “I will arrange for prophylactic care prior to having dental treatments.”
(d) “I will avoid extremes of hot and cold weather.”
Answer:
(c) “I will arrange for prophylactic care prior to having dental treatments.”

Nursing Process: Evaluation/Medical 

Rationale: 
Hemophiliac patients should prepare for dental procedures such as extractions by consulting both the dentist and their hematologist for clotting factor replacement therapy, antifibrinolytic agents, and local hemostatic measures. Patients with hemophilia should avoid contact sports. Over-the-counter medications containing aspirin or NSAIDs, which can precipitate or prolong bleeding, should be avoided. Temperature extremes do not influence hemophilia.

Question 58.
Which of the following is a true statement regarding restraining a patient when necessary?
(a) Utilize a trained and coordinated team approach.
(b) Have the strongest members of the staff overpower the patient.
(c) Direct the patient to cooperate or law enforcement will be called.
(d) Engage family members to physically assist.
Answer:
(a) Utilize a trained and coordinated team approach.

Nursing Process: Intervention/Psychosocial 

Rationale: 
This is a high-risk situation for both the patient and staff. A trained team approach that has been practiced outside of emergent circumstances is indicated. Attempting to use the strongest staff approach is likely to harm both the patient and the provider. Threatening the patient with police intervention is abusive and not likely to result in a therapeutic result. Family should not be allowed to participate in such an intervention.

Question 59.
The Health Insurance Portability and Accountability Act (H1PAA) includes protected information in public venues. However, protected health information can be shared without patient consent in which of the following situations?
(a) Insurance companies for billing purposes 
(b) To an ex-spouse for legal recovery of information 
(c) EMS to determine patient’s marital status 
(d) To share with neighbors or friends who call
Answer:
(a) Insurance companies for billing purposes 

Cognitive Level: Application/Professional Issues 

Rationale: 
Insurance companies are included in the transmission of protected health information. It would not be appropriate to give the information to individuals (such as the ex-wife/husband or friends who call in). EMS personnel would already have the patient’s consent because they brought the patient into the hospital. The Privacy Rule protects all “individually identifiable health information” held or transmitted by a covered entity (i.e., hospital) or its business associate, in any form or media (whether electronic, paper, or oral). The hospital may share protected health information (PHI) during the course of treatment, payment, and healthcare operations.

Question 60.
When caring for a case involving forensics, which of the following is an important concept?
(a) Cut off clothing through holes and stains/
(b) Place all clothing together in one neat pile.
(c) Package each piece of clothing in a plastic airtight bag.
(d) Use paper bags with tamper-resistant seal for evidence.
Answer:
(d) Use paper bags with tamper-resistant seal for evidence.

Cognitive Level: Analysis/Professional Issues 

Rationale: 
Paper allows the evidence to breathe, whereas plastic could destroy the evidence with mold and other issues. Applying and initialing the seals ensures the safety of the evidence as the tape is designed to fracture easily to indicate tampering. When cutting the clothing off a patient, never cut through any cuts, holes, or other marks that may be entrance/exit wounds or contain evidence. It is important these areas be left unaltered. Each piece of evidence should be gathered separately to avoid cross-contamination, not piled on top of each other.

Question 61.

Which of the following identifies the significance of the above rhythm?
(a) Hyperkalemia; tall, peaked T waves; and early hyperacute sign
(b) T-wave inversion, ischemia, and T wave appears deep and symmetrical
(c) Injury pattern and elevation above the isoelectric line indicate acuteness of injury 
(d) Pathologic Q wave appears within 24 hours of infarct and may remain permanent
Answer:
(c) Injury pattern and elevation above the isoelectric line indicate acuteness of injury 

Nursing Process: Analysis/Cardiovascular 

Rationale: 
ST-elevation myocardial infarction (STEMI) is characterized by ST-segment elevation in two or more contiguous leads and threshold values of J-point elevation greater than 2 mm in leads V2 and V3 and 1 mm or more in all other leads. This is ST elevation, not peaked or inverted waves; tall T waves can signify hyperkalemia, cerebrovascular injury, and left ventricular volume loads, resulting from mitral or aortic regurgitation. T-wave inversion can have various causes, including ischemia or evolving myocardial infarction or cerebrovascular accidents. Pathologic Q waves appear within 24 hours of infarction at greater than 0.04 seconds in duration or greater than 25 % of the R wave in depth. These indicate necrosis in the heart muscle and can be permanent.

Question 62.
A patient is transported via EMS to the emergency department after having fallen from a roof. On assessment, the nurse notes lack of breath sounds on the left side. A chest tube is inserted in the left chest, but instead of releasing air, the catheter expels blood. Which of the following might be the reason for this?
(a) Tension pneumothorax 
(b) Open pneumothorax 
(c) Hemothorax 
(d) Simple pneumothorax
Answer:
(c) Hemothorax 

Nursing Process: Analysis/Respiratory 

Rationale: 
A hemothorax is caused by free blood in the pleural space, usually caused by trauma, which will result in diminished or absent breath sounds on the affected side. A tension pneumothorax or simple pneumothorax will not expel blood through the chest tube. An open pneumothorax will present with a bubbling, sucking noise at the site of injury but will not usually be associated with loss of blood.

Question 63.
Which of the following is a true statement regarding emphysema?
(a) Emphysema creates increased dead space in the lung fields.
(b) An emphysemic patient is one who develops cor pulmonale.
(c) A stocky build is a normal body shape for emphysemic patients.
(d) Respiratory infections are dominant in the patient with emphysema.
Answer:
(a) Emphysema creates increased dead space in the lung fields.

Nursing Process: Analysis/Respiratory 

Rationale: 
An increase in dead space occurs with emphysema because of destruction of alveolar walls and overdistention of the alveoli. When this happens, these alveoli are no longer functional because they cannot participate in diffusion of gases. This increases dead space - a space where air is transported but does not assist with the work of the pulmonary system such as with the trachea. Cor pulmonale, right-sided heart failure caused by a pulmonary issue, is associated with chronic bronchitis. Chronic bronchitis patients usually have a stocky build as opposed to the thin extremities and barrel chest of the emphysema patient and respiratory infections are more prone in the chronic bronchitis patient due to the increase in secretions.

Question 64.
Allergic stings are most commonly caused by which of the following?
(a) Hornets 
(b) Scabies 
(c) Bumble bees 
(d) Bed bugs
Answer:
(a) Hornets 

Nursing Process: Analysis/Medical 

Rationale: 
Hornets, yellow jackets, and wasps are the leading cause of allergic stings. They are aggressive and can sting repeatedly with minimal provocation. Scabies is an intensely itchy skin infestation caused by a mite. It does not produce an allergic reaction. Bumble bees can produce an allergic reaction but are much less aggressive and sting with much lower frequency. Bed bugs are parasitic insects that feed on blood. The bite produces a painless, pruritic lesion. Urticaria may develop from repeated exposure.

Question 65.
A patient in the triage area is yelling and becoming increasingly agitated; he throws his bottle of water on the floor. The family states this agitated and aggressive behavior is new over the past few hours. Which of the following is the best response for the triage nurse at this time?
(a) Approach the patient and directly confront him to control him through authority.
(b) Inform the patient that this is not an acceptable behavior in the emergency department.
(c) Reassure the patient that the nurse is here to help him.
(d) Shout for security to call the police immediately.
Answer:
(c) Reassure the patient that the nurse is here to help him.

Cognitive Level: Application/Professional Issues 

Rationale: 
The patient is exhibiting excessive agitation, which has a potential for violence; therefore, reassuring the patient and his family is the most therapeutic response. The nurse should avoid being within the patient’s physical reach to reduce the risk of being hit. Taking an authoritative stance is likely to further agitate the patient. He may not be able to cognitively take verbal cueing or instructions because of an underlying pathologic process. Shouting that outside authorities should be called will also likely incite further agitation.

Question 66.
The emergency nurse recognizes which of the following as common causes or precipitants of supraventricular tachycardia?
(a) Digoxin, beta-blockers, and calcium channel blockers
(b)  Hypoxia, ischemia, heart failure, myocardial infarction, caffeine, and alcohol 
(c) Hypertension, atherosclerosis, chronic cocaine use, and cardiac surgery
(d) Thrombosis, vasospasm, cocaine use, and chemotherapeutic agents
Answer:
(b)  Hypoxia, ischemia, heart failure, myocardial infarction, caffeine, and alcohol 

Nursing Process: Analysis/Cardiovascular 

Rationale: 
Common causes of supraventricular tachycardia include hypoxia, ischemia, heart failure, myocardial infarction, mitral valve prolapse, caffeine, alcohol, recreational drugs, and hyperthyroidism. Digoxin, beta-blockers, calcium channel blockers, increased vagal tone on the sinoatrial node, and myocardial ischemia or infarction (depending on the vessel occluded) are common causes of sinus pause or sinus arrest. Hypertension, atherosclerosis, chronic cocaine use, and cardiac surgery may lead to aortic aneurysm. Thrombosis, vasospasm, cocaine use, chemotherapeutic agents, and serotonin receptor agonists are risk factors for ST-elevation myocardial infarction.

Question 67.
Which of the following arterial blood gas (ABG) readings is correct for the following results?
pH—7.52 
pCO2—22 mm Hg 
HCO3—26 mEq/L 
PaO2—92 mm Hg
(a) Respiratory acidosis 
(b) Respiratory alkalosis 
(c) Metabolic acidosis 
(d) Metabolic alkalosis
Answer:
(b) Respiratory alkalosis 

Nursing Process: Analysis/Respiratory 

Rationale: 
Correct interpretation of these blood gas values is respiratory alkalosis. The pH determines whether the reading is acidotic or alkalotic, and because this is greater than 7.45, the patient is alkalotic. Normal pH is 7.35 to 7.45. The next determination is whether the problem is related to carbon dioxide or bicarbonate. The parameter that is not normal is the pCO₂ level with the bicarbonate level being within normal limits. Also, the pH and the respiratory components are opposite each other, that is, the pH is "up” and the CO₂ is “down.” This meets criteria for a diagnosis of respiratory alkalosis. A common problem that creates this blood gas reading is hyperventilation. Metabolic problems are directly related to each other, thus, a metabolic alkalosis would show an increase in both the pH and the HCO₃. The PaO₂ is normal.

Question 68.
A patient without human immunodeficiency virus (HIV) infection has a tuberculin skin test (purified protein derivative [PPD]). Which of the following is considered a positive result?
(a) Redness >10 mm 
(b) Induration >10 mm 
(c) Redness of 5 mm 
(d) Induration of 5 mm
Answer:
(b) Induration >10 mm 

Nursing Process: Evaluation / Communicable 

Rationale: 
If a patient has HIV infection, induration of 5 mm or more is considered a positive result. Induration 10 mm or more is considered a positive PPD result in the absence of HIV infection. Redness may be related to an allergic process but is not considered a positive PPD finding. If a patient has HIV infection, induration of 5 mm or more is considered a positive result.

Question 69.
A delivery occurs in the emergency department. The baby presents with blue limbs, pink body, heart rate of 142 beats/minute, some flexion, some motion, and a weak cry. What is this infant’s APGAR score? 
(a) 10 
(b) 9 
(c) 7 
(d) 6
Answer:
(d) 6

Nursing Process: Assessment/GU/GYN/OB 

Rationale: 
According to the APGAR scoring scale, this infant would receive 1 point for the flexion (Activity or muscle tone); 2 points for Pulse rate, which is over 100 beats/minute; 1 point for the motion activity (Grimace or reflex irritability); 1 point for the blue limb color with the pink body (Appearance); and 1 point for the weak cry (Respirations). This equals a scoring of 6.

Question 70.
A patient in her 34th week of pregnancy presents to the emergency department. Her blood pressure is 180/110 mm Hg and she complains of headache and blurred vision. During treatment of this patient, the emergency nurse should be prepared for which of the following complications?
(a) Precipitous delivery 
(b) Vaginal bleeding 
(c) Cardiac dysrhythmias 
(d) Seizure activity
Answer:
(d) Seizure activity

Nursing Process: Evaluation/GU/GYN/OB 

Rationale: 
This scenario provides information for symptoms associated with pregnancy-associated hypertension; the patient has a potential for seizure activity because of central nervous system irritability. Seizure precautions should be, instituted. Precipitous delivery, vaginal bleeding, and cardiac dysrhythmias are not complications of pregnancy-associated hypertension.

Question 71.
Neurotoxin released by the black widow spider can lead to:
(a) hypotension and tachycardia.
(b) urticaria and necrosis.
(c) tingling and muscle fasciculation.
(d) hemolysis and renal failure.
Answer:
(c) tingling and muscle fasciculation.

Nursing Process: Assessment/Environmental 

Rationale: 
Black widow spider neurotoxin causes nausea and weakness as well as hypertension and tachycardia. Other symptoms include muscle fasciculations, spasm, tingling, altered mental status, and potentially seizures. Renal failure from hemolysis can occur with brown recluse bites. Brown recluse bites, not black widow, can demonstrate urticaria and a necrotic wound.

Question 72.
Which of the following is the primary physiologic reason for hypotension and bradycardia in neurogenic shock?
(a) Third spacing of intracellular fluid 
(b) Disruption in sympathetic nervous system 
(c) Hypersensitivity to allergen 
(d) Left ventricular hypertrophy
Answer:
(c) tingling and muscle fasciculation.

Nursing Process: Assessment/Neurologic/Shock 

Rationale: 
Neurogenic shock occurs when there is a disruption in the sympathetic nervous system, allowing the parasympathetic nervous system to take over, which causes hypotension and bradycardia. No other form of shock causes these connected symptoms. Third spacing of intracellular fluid leads to hypovolemia. Left ventricular hypertrophy may be a contributing factor for cardiogenic shock. A hypersensitivity reaction would involve anaphylactic shock.

Question 73.
Screening questions to identify human trafficking must be brief and limited because the perpetrator will not leave the victim alone for long. Simple screening questions include all of the following EXCEPT:
(a) “Are the doors and windows locked so you cannot leave?”
(b) “Has your ID or documentation been taken from you?”
(c) “Have you been denied food, water, sleep, or medical care?”
(d) “What is your! cell phone number so we can reach you?”
Answer:
(d) “What is your! cell phone number so we can reach you?”

Cognitive Level: Analysis/Professional Issues

Rationale: 
Asking for a cell phone number may trigger fear in the victim that the perpetrator will find out and/or that the victim “said too much.” All the other questions are brief, appropriate, and can be answered quickly.

Question 74.
A registered nurse reads a journal’s research study. The study taught fever control measures to first-time parents. Which of the following is most important to determine before attempting to apply the same project in the nurse’s emergency department?
(a) Was the study approved by an Institutional Review Board (IRB)?
(b) What was the actual content that the researcher taught to the parents?
(c) Are the researcher's and nurse’s settings similar enough for transferability?
(d) Did the researcher statistically verify the data results with an analysis of variance (ANOVA)?
Answer:
(c) Are the researcher's and nurse’s settings similar enough for transferability?

Cognitive Level: Application/Professional Issues 

Rationale: 
To apply the study, the two settings need to be similar enough to allow transferability. It would not be as effective, for instance, if the emergency department in the study was an inner-city teaching facility treating 200 patients a day and the nurse reading the study worked at a small community hospital with 20 patients a day. An institutional review board (IRB) is a type of committee that applies research ethics by reviewing the methods proposed for research to ensure that they are ethical. They also ensure the rights of the subjects. Such boards are formally designated to approve (or reject), monitor, and review biomedical and behavioral research involving humans. It is essential to know the content of the teaching so it can be implemented, but transferability needs to be determined first. ANOVA is one statistical option for testing differences among three or more group means.

Question 75.
A patient has fever, gingival pain, bleeding gums, and foul breath. The patient is suspected of having trench mouth. Which of the following of the following is another term for this disorder?
(a) Ludwig’s angina 
(b) Vincent’s angina 
(c) Pericoronitis 
(d) Dental abscess
Answer:
(b) Vincent’s angina 

Nursing Process: Assessment/Maxillofacial/Ocular 

Rationale: 
Vincent’s angina also referred to as. acute necrotizing ulcerative gingivitis or trench mouth is a bacterial infection of the gums. Classic presentation of Vincent’s angina includes bleeding, painful, swollen gums, fever, halitosis, and gray pseudomembranous ulcers on the pharynx. Ludwig’s angina is bacterial invasion of the submandibular structures. Pericoronitis is inflammation of the gingival tissue around the crown of an erupting or impacted tooth. Dental abscess is the localized accumulation of pus in various regions of the tooth and gum. Dental abscess can lead to complications of Vincent’s or Ludwig’s angina. 

Question 76.
Which of the following areas of the brain controls the respiratory and cardiac systems?
(a) Medulla 
(b) Frontal lobe 
(c) Diencephalon 
(d) Hypothalamus
Answer:
(a) Medulla 

Nursing Process: Analysis/Neurologic 

Rationale: 
The medulla controls the arterioles, the blood pressure, and the rate and depth of respirations. Severe injury to this area generally results in death. The medulla also controls yawning, coughing, vomiting, and hiccoughing. The frontal lobe of the cerebrum controls personality, judgment, thought, and logic. The diencephalon contains the thalamus, which is the sensory pathway between the spinal cord and the cortex of the brain. The hypothalamus regulates body temperature, appetite, and sleep.

Question 77.
Which of the following statements made by a patient indicates the need for further instruction about the treatment of bacterial conjunctivitis?
(a) “I can use disposable daily contact lenses since starting antibiotic ointment.”
(b) “I will discard all of my old eye makeup and clean my makeup brushes.”
(c) “I will avoid use of eye makeup until the infection is gone.”
(d) “Warm compresses will help to remove discharge from my eyelids.”
Answer:
(a) “I can use disposable daily contact lenses since starting antibiotic ointment.”

Nursing Process: Evaluation/Maxillofacial/Ocular 

Rationale: 
Contact lenses should not be worn at all during a bout with conjunctivitis. Bacterial conjunctivitis is highly contagious. Infection control measures include handwashing, instillation of antibiotic ophthalmic ointment, eye cleansing procedure, avoiding use of eye makeup, and discarding previously used eye makeup.

Question 78.
When treating an acutely psychotic patient, all of the following are appropriate EXCEPT:
(a) reorienting them back to reality as frequently as necessary.
(b) policy requirement of mandatory seclusion or four-point restraints.
(c) comprehensive assessment for potential medical causes of their psychosis.
(d) escalation of restrictive intervention to protect them and others from harm.
Answer:
(b) policy requirement of mandatory seclusion or four-point restraints.

Nursing Process: Intervention/Psychosocial 

Rationale: 
Policy requirement of mandatory seclusion or restraints for a diagnosis is not appropriate. The acutely psychotic patient may require frequent reorientation to reality. Ruling out medical causes of psychosis is a standard of care. The decision for the level of restraint necessary should be borne in assessment and should progress from the least restrictive to the level necessary to protect the patient and others.

Question 79.
The absence of the cremasteric reflex has a high sensitivity but low specificity for which of the following conditions?
(a) Penile foreign body 
(b) Testicular torsion 
(c) Urethral tear
(d) Epididymitis
Answer:
(b) Testicular torsion 

Nursing Process: Assessment/GU/GYN/OB 

Rationale: 
The cremasteric reflex is characterized by the normal elevation of the testes that occurs when the upper medial thigh is stroked. This will not be present if there is a testicular torsion. A penile foreign body, urethral tear, or epididymitis does not have this as a manifestation of these processes.

Question 80.
A paraplegic patient presents to the emergency department complaining of a headache. He is noted to be flushed and is sweating profusely. Which of the following should be the first action for this patient?
(a) Apply compression stockings.
(b) Lower his head to increase cerebral circulation.
(c) Massage lower extremities to cause vasodilation.
(d) Assess for a blocked urinary catheter.
Answer:
(d) Assess for a blocked urinary catheter.

Nursing Process: Intervention/Neurologic 

Rationale: 
This patient is demonstrating manifestations of autonomic dysreflexia. This is the sudden onset of an abnormal sympathetic nervous system response to a noxious stimuli such as a full bladder, full rectum, or pressure on an ulcer. The symptoms include bradycardia, hypertension, headache, flushing, and excessive sweating. Emergency treatment involves raising the head of the bed and loosening any constricting clothing. If compression stockings are present on the patient, they should be removed to encourage venous pooling. The most important intervention for this response is to resolve the offending stimulus. Assess for G-I-related or G-U-related situations. Often irrigation of a urinary catheter or unkinking the tubing may relieve the sympathetic response. Enemas or removal of an impaction may be necessary. Antihypertensives can be given but the hypertension will not resolve until the stimulus has been removed.

Question 81.
Causes of disseminated intravascular coagulopathy (DIC) include all of the following EXCEPT:
(a) sepsis.
(b) hemolytic transfusion reaction.
(c) idiopathic thrombocytopenia.
(d) transplant rejection.
Answer:
(c) idiopathic thrombocytopenia.

Nursing Process: Analysis/Medical

Rationale: 
Idiopathic thrombocytopenia is a disease of increased peripheral platelet destruction, commonly seen in children several weeks after a viral infection such as chickenpox or rubella. DIC is a thrombohemor-rhagic disorder involving inappropriate and accelerated stimulation of the clotting cascade. Common causes include sepsis, a hemolytic transfusion reaction, transplant rejection as well as massive blood transfusions, major trauma, and obstetrical complications such as abruptio placentae and retained placenta.

Question 82.
Which of the following symptoms would be indicative of the compensatory stage in hypovolemic shock?
(a) Narrowing pulse pressure 
(b) Severe hypotension 
(c) Increasing lactic acid level 
(d) Increasing urine output
Answer:
(d) Increasing urine output

Nursing Process: Evaluation/Ortho/Shock 

Rationale: 
Increasing urine output indicates that renal perfusion is maintained and is a sign of compensated hypovolemic shock. A narrowing pulse pressure, severe hypotension, and increased lactic acid levels are indicative of uncompensated forms of shock. 

Question 83.
A patient presents with high fever and the following signs and symptoms affecting the right ear: swelling, erythema and pain to the pinna, otorrhea, and decreased hearing. The emergency nurse prepares interventions for which of the following?
(a) Ruptured tympanic membrane
(b) Parotitis
(c) Otitis externa
(d) Mastoiditis
Answer:
(d) Mastoiditis

Nursing Process: Assessment/Maxillofacial/Ocular 

Rationale: 
Acute mastoiditis is an inflammatory process secondary to bacterial infection of the mastoid air cells of the temporal bone. It may occur with an associated otitis media. Presentation includes fever, inflammation, and erythema to the mastoid and auricle, otorrhea, hearing loss, and deep, localized pain behind the ear. A ruptured tympanic membrane may result in impaired hearing, vertigo, and drainage (blood) from the ear. Parotitis is inflammation of the parotid gland and presents with unilateral swelling below the ear and jaw. Otitis externa is an infection and inflammation of the auditory canal and may present with itching of the ear canal and external ear, pain with movement of the ear, and swelling of the ear canal. Fever is not a classic symptom of otitis externa.

Question 84.
The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that a patient with no insurance:
(a) should be transferred to a teaching hospital that receives federal funds.
(b)  must be transferred to a Level I trauma center as soon as possible.
(c) should be transferred if the receiving hospital can provide addition care.
(d) cannot be transferred to another facility, as defined by the COBRA law.
Answer:
(c) should be transferred if the receiving hospital can provide addition care.

Cognitive Level: Application/Professional Issues 

Rationale: 
EMTALA is a federal law that requires hospital emergency departments to medically screen every patient who seeks emergency care and to stabilize or transfer those with medical emergencies, regardless of health insurance status or ability to pay. This law has been an unfunded mandate since it was enacted in 1986. Transferring to a teaching hospital is not part of the process. Patients should be transferred to an appropriate hospital relative to the illness or injury and must be stabilized before the transfer.

Question 85.
When caring for a sexually assaulted patient, the highest priority would be:
(a) evidence collection and preservation.
(b) report of the crime to authorities.
(c) caring for injuries sustained in the assault.
(d) updating her family and friends.
Answer:
(c) caring for injuries sustained in the assault.

Nursing Process: Analysis/GU/GYN/OB 

Rationale: 
The patient’s well-being is always the priority. Evidence collection and preservation and encouraging police involvement are important but is not the priority. Notifying family and friends is up to the discretion of the patient.

Question 86.
Which of the following should be performed by the emergency nurse caring for a patient with suspected Herpes Zoster (shingles)?
(a) Place the patient in a negative-pressure room 
(b) Administer postexposure prophylaxis 
(c) Place the patient on contact precautions 
(d) Wear an N-95 respiratory mask
Answer:
(c) Place the patient on contact precautions 

Nursing Process: Intervention/Communicable 

Rationale: 
Herpes Zoster is spread via direct contact with the herpetic lesions. Negative-pressure isolation is indicated for airborne, not contact, isolation. A patient who is already symptomatic will not benefit from post-exposure prophylaxis. The N-95 respiratory mask is required for droplet infections such as tuberculosis.

Question 87.
Which of the following would be most concerning regarding a patient diagnosed with heat stroke?
(a) Persistent lack of shivering
(b) Pink/reddish-colored urine 
(c) Sinus tachycardia on the monitor 
(d) Presence of a Lichtenberg Figure
Answer:
(b) Pink/reddish-colored urine 

Nursing Process: Analysis/Environmental 

Rationale: 
One of the consequences of heat exhaustion is the breakdown of skeletal muscle tissue, leading to rhabdomyolysis which presents as pinkish to dark red-colored urine. This occurs because of the release of myoglobin into the plasma. “Rhabdo” can lead to renal failure if sufficient fluids are not flushed through the kidneys. One of the challenges when cooling a hyperthermic patient is preventing shivering because this actually creates heat. Sinus tachycardia is expected. A Lichtenberg Figure is associated with a lightning strike at the point of entry. This transient discoloration lasts for only a few hours.

Question 88.
A patient presents with an ingestion of an unknown substance. The emergency nurse notes the patient to have bradycardia, diminished bowel sounds, miosis, and cool, dry skin. Which of the following agents did the patient most likely ingest?
(a) Opioid 
(b) Anticholinergic 
(c) Sedative-hypnotic 
(d) Sympathomimetic
Answer:
(a) Opioid 

Nursing Process: Assessment/Toxicology 

Rationale: 
The opioid toxidrome includes bradycardia, constricted pupils (miosis), hypotension, hypothermia, diminished bowel sounds, bradypnea, and no change in diaphoresis; therefore, opioids would be the most likely choice in this scenario. Anticholinergics and sympa- thomimetics are known to have tachycardia, rather than bradycardia, mydriasis (dilated pupils) rather than miosis, and increased body temperature. Sedative hypnotics are known to cause bradycardia, diminished bowel sounds, and cool, dry skin, but are not associated with miosis.

Question 89.
Which of the following would indicate an improvement in a patient experiencing neurogenic shock associated with a spinal cord injury?
(a) Heart rate of 46 beats/minute 
(b) Blood pressure of 90/62 mm Hg 
(c) Temperature of 98.6° F (37° C)
(d) Respiratory rate of 28 breaths/minute
Answer:
(c) Temperature of 98.6° F (37° C)

Nursing Process: Evaluation/Neurologic/Shock 

Rationale: 
Patients with neurogenic shock associated with spinal cord injuries have difficulty maintaining their temperature control. This is known as poikilothermia. A normalized temperature would be a positive turn for a patient with this type of shock. A heart rate of 46 beats per minute would be part of the symptomatology for neurogenic shock as would the hypotension and the rapid breathing.

Question 90.
Which of the following does the emergency nurse prepare the patient for in the treatment of iritis?
(a) Installation of antibiotic ophthalmic ointment 
(b)  Eye flush with normal saline 
(c) Cold compress to the eye 
(d) Instillation of ophthalmic steroids
Answer:
(d) Instillation of ophthalmic steroids

Nursing Process: Intervention/Maxillofacial/Ocular 

Rationale: 
Iritis is an inflammatory process that may be idiopathic or secondary to systemic inflammatory disorders. Instillation of topical ophthalmic steroids and cycloplegic agents is indicated to treat the inflammation and reduce ciliary spasms. Warm compresses and resting the eye by darkening the environment is indicated. There is no therapeutic benefit of instilling antibiotic ointment or flushing the eyes, because neither of these interventions will directly decrease the inflammation.

Question 91.
Which of the following is an indication for an emergency resuscitative thoracotomy?
(a) Patients sustaining penetrating abdominal injuries 
(b) Blunt trauma with no signs of life 
(c) Penetrating thoracic wound with recent loss of vital signs
(d) Qualified trauma surgeon is not available.
Answer:
(c) Penetrating thoracic wound with recent loss of vital signs

Nursing Process: Intervention/Cardiovascular 

Rationale: 
Penetrating thoracic wounds with recent loss of vital signs is an indication for an emergency thoracotomy in order to determine the site of injury and stop persistent hemorrhage. Penetrating abdominal injuries and blunt trauma with no signs of life are not indications for an emergency thoracotomy. A qualified surgeon who is available as back-up is an indication for emergency thoracotomy to take the patient to the operating room for definitive repair.

Question 92.
Which of the following is NOT an appropriate intervention for the child with suspected epiglottitis?
(a) Obtaining a throat culture
(b) Providing supplemental oxygen 
(c) No invasive procedures 
(d) Lateral neck radiograph
Answer:
(a) Obtaining a throat culture

Nursing Process: Intervention/Respiratory 

Rationale:
Obtaining a throat culture can lead to increased airway obstruction due to initiation of epiglottic spasm when irritating with the swab and, as such, would not be an appropriate intervention. Epiglottitis is a true medical emergency due to the abrupt inflammation of the epiglottis causing airway obstruction. A lateral neck radiograph may indicate epiglottic and aryepiglottic swelling, referred to as the “thumbprint sign” and the “posterior triangle.” The treatment goal is to maintain the airway until surgical capability in the operating room (OR) is possible. This is accomplished by providing supplemental oxygen as tolerated and performing no invasive procedures until the airway is secure.

Question 93.
Assessment of an unrestrained patient from a motor vehicle crash reveals hypotension, warm, dry skin, and bradycardia. Which of the following is the most likely cause?
(a) Cardiogenic shock 
(b) Neurogenic shock 
(c) Hypovolemic shock 
(d) Septic shock
Answer:
(b) Neurogenic shock 

Nursing Process: Assessment/Neurologic/Shock 

Rationale: 
Bradycardia is the hallmark symptom of neurogenic shock. Spinal trauma, from a motor vehicle crash, may cause an interruption in the sympathetic nervous system integrity. Although the patient may be hypotensive, the skin is often warm and dry in neuro-genic shock. Hypovolemic, septic, and cardiogenic shock would most likely have tachycardia, hypotension, and cool, moist skin.

Question 94.
On assessment of a patient with a suspected single-drug intentional overdose, the emergency nurse notes dilated pupils, hypoactive bowel sounds, and hot, dry, and flushed skin. Which of the following medications would be the most likely source of the overdose based on the symptoms present?
(a) Alprazolam (Xanax)
(b) Amitriptyline (Elavil)
(c) Methylphenidate (Ritalin)
(d) Morphine sulfate (Roxanol)
Answer:
(b) Amitriptyline (Elavil)

Nursing Process: Analysis/Toxicology 

Rationale: 
Based on this information and findings of this patient, the only medication that fits all the criteria for this toxidrome is amitriptyline (Elavil). The four medications listed are from the toxidromes of sedatives (alprazolam), anticholinergics (amitriptyline), sympathomimetics (methylphenidate), and opioids (morphine sulfate). The symptoms for anticholinergics include tachycardia, dilated pupils (mydriasis), hypertension, hyperthermia, decreased bowel sounds, tachypnea, and dry skin. The symptoms for opioids include bradycardia, constricted pupils (miosis), hypotension, hypothermia, decreased bowel sounds, bradypnea, and no effect on diaphoresis. The symptoms for sedatives include bradycardia, hypotension, hypothermia, decreased bowel sounds, bradypnea, and no effect on diaphoresis or pupil size. The symptoms for sympathomimetics include tachycardia, dilated pupils (mydriasis), hypertension, hyperthermia, tachypnea, and diaphoresis, and bowel sounds may be hypoactive or hyperactive.

Question 95.
A group of nursing friends are attending a nursing conference in a mountainous area. On arrival, several of the group members become irritable and are complaining of persistent headache, nausea, and extreme fatigue. There is a planned event that afternoon to the summit of one of the near mountains. Which of the following would be the best recommendation for those feeling ill?
(a) Take 1,000 mg acetaminophen, increase fluids, and attend the trip.
(b) Drink two large glasses of nonalcoholic fluids, rest, and decline the trip.
(c) Increase noncaffeinated fluids, eat some protein, and attend the trip.
(d) Eat and drink normally, go on the trip, but decline the hike.
Answer:
(b) Drink two large glasses of nonalcoholic fluids, rest, and decline the trip.

Nursing Process: Intervention/Environmental 

Rationale: 
At 4,900 feet, oxygen does not attach to hemoglobin as readily, leading to symptoms of tissue hypoxia which can include headache, fatigue, nausea, weakness, irritability, and dehydration. Acute mountain sickness, the milder form of altitude sickness, typically improves with rest, fluids, and time as the ^ body acclimates to the altitude and the patient feels better within a day or two. Ascending higher into the mountains will increase symptoms and may progress to high-altitude cerebral edema (HACE) or high-altitude pulmonary edema (HAPE). Activities such as hiking will increase symptoms and risk. Going on the trip higher into the mountain is ill-advised.

Question 96.
Two hours after taking an overdose of acetaminophen (Tylenol), a patient arrives in the emergency department. Based on the nomogram for acute ingestion, when can emergency the nurse expect to draw a blood acetaminophen level?
(a) Immediately 
(b) In 1 hour 
(c) In 2 hours 
(d) In 4 hours
Answer:
(c) In 2 hours 

Nursing Process: Intervention/Toxicology 

Rationale: 
Based on nomogram for acute ingestion, serum acetaminophen levels should be drawn 4 hours after ingestion. Since the ingestion occurred 2 hours before arrival, the level should be drawn 2 hours after arrival to reach the 4-hour level. Levels drawn sooner or later would not reflect the peak acetaminophen level. An acetaminophen level greater than 150 g/mL 4 hours after ingestion indicates toxicity.

Question 97.
A patient with a diagnosis of ischemic stroke is being prepped for the initiation of TPA (tissue plasminogen activator). The patient is on the cardiac monitor. Oxygen has been applied at 2 L/nasal cannula. Labetalol (Normodyne) 5 mg intravenous was administered. A light, warm blanket has been applied. Which of the following would indicate that proper interventions have been completed that allow for the administration of this medication?
(a) Pulse rate of 120 beats/minute 
(b) Blood pressure of 168/98 mm Hg 
(c) Pulse oximetry reading of 94%
(d) Temperature of 98.6° F (37° C)
Answer:
(b) Blood pressure of 168/98 mm Hg 

Nursing Process: Evaluation/Neurologic 

Rationale: 
According to the stroke guidelines for care, a systolic blood pressure above 180 mm Hg requires treatment before the initiation of TPA. Labetalol (Normodyne) was given prior with a blood pressure now of 168/98 mm Hg, which demonstrates that the Labetalol (Normodyne) was successful in lowering the systolic pressure below 185 mm Hg. A systolic blood pressure that remains above 185 mm Hg is a contraindication to TPA initiation. Acceptable pressures are systolic below 185 mm Hg and diastolic below 110 mm Hg. Uncontrolled hypertension increases the risk of intracranial bleeding. Tachycardia would not necessarily contraindicate the administration unless it was associated with bleeding/hypovolemia. The pulse oximetry reading and temperature are not included in the criteria, although it is recommended to supplement for Sat02 below 94 %. Hyperthermia can increase the morbidity rate, but in this scenario, the temperature is normal and a light, warm blanket was applied for patient comfort.

Question 98.
Which of the following two extracellular substances work together to regulate pH?
(a) Sodium bicarbonate and acetic acid 
(b) Sodium bicarbonate and carbonic acid 
(c) Sodium bicarbonate and sodium hydroxide 
(d) Sodium bicarbonate and carbon dioxide
Answer:
(b) Sodium bicarbonate and carbonic acid 

Nursing Process: Analysis/Medical 

Rationale: 
Sodium bicarbonate and carbonic acid are the two primary extracellular regulators of pH. pH is also further regulated by electrolyte composition within the intra- and extracellular compartments. Acetic acid is commonly known as vinegar and is not an extracellular substance in the human body. Carbon dioxide combines with water to form carbonic acid. Sodium hydroxide is lye or caustic acid and is not found in the body.

Question 99.
A patient in her 34th week of pregnancy comes to the emergency department and complains of sudden onset of bright red vaginal bleeding. Her uterus is soft, and she is not experiencing any pain. Fetal heart tones are 120 beats/minute. Based on this history, the emergency nurse should suspect which of the following conditions?
(a) Abruptio placentae 
(b) Preterm labor 
(c) Placenta previa 
(d) Threatened abortion
Answer:
(c) Placenta previa 

Nursing Process: Analysis/GU/GYN/OB 

Rationale: 
Placenta previa is associated with painless vaginal bleeding that occurs when the placenta, or a portion of the placenta, covers the cervical os. Serious hemorrhage can occur. In abruptio placentae, the placenta tears away from the wall of the uterus before delivery. The patient usually has pain and a board-like uterus. Preterm labor is associated with contractions and should not involve bright red bleeding. By definition, threatened abortion occurs during the first 20 weeks of gestation.

Question 100.
Which of the following is the drug of choice for the treatment of cardiogenic shock?
(a) Dopamine (Intropin)
(b) Dobutamine (Dobutrex)
(c) Nitroglycerin (Trinitrate)
(d) Vasopressin
Answer:
(b) Dobutamine (Dobutrex)

Nursing Process: Intervention/Cardiovascular/Shock 

Rationale: 
Dobutamine is a potent vasopressor but has less of a tendency to increase the heart rate as opposed to dopamine. Tachycardia is a dangerous side effect of Dopamine and can worsen cardiogenic shock due to to the increased myocardial demands. Therefore, Dobuta-mine is the preferred drug for cardiogenic shock. Vasopressin is used to treat hypotension in patients who are suffering from a vasodilatory type of shock. It is used for these patients after no response from fluid boluses and catecholamine infusions. Nitroglycerin is a nitrate utilized in the treatment of angina and congestive heart failure associated with a myocardial infarction and renal failure. Nitroglycerin would bring blood pressures down due to its vasodilatory effects. It would be contraindicated in hypotension.

Question 101.
Septic shock in a pediatric patient often has which of the following associated clinical assessment findings?
(a) Projectile vomiting 
(b) Pulmonary edema 
(c) Petechial rash 
(d) Jugular venous distention
Answer:
(c) Petechial rash 

Nursing Process: Assessment/Medical/Shock 

Rationale: 
Sepsis in a pediatric patient is often accompanied by a petechial rash, usually secondary to an overwhelming infectious process, such as meningococcemia. Projectile vomiting may be a sign of increased intracranial pressure. Pulmonary edema and jugular venous distension are associated with cardiogenic shock.

Question 102.
A patient presents to the emergency department complaining of pain in her jaw. The emergency nurse notes facial drooping to the corner of the mouth on the left side. Which of the following cranial nerves (CNs) is affected?
(a) Cranial Nerve VI (Abducens) 
(b) Cranial Nerve VIII (Acoustic)
(c) Cranial Nerve V (Trigeminal)
(d) Cranial Nerve III (Oculomotor)
Answer:
(c) Cranial Nerve V (Trigeminal)

Nursing Process: Analysis/Neurologic

Rationale: 
Cranial Nerve V (Trigeminal) deals with facial, cheek, and chin movement. Cranial Nerve III (Oculomotor) constricts the pupil and is responsible for helping with eyeball movement. Cranial Nerve VI (Abducens) rotates your eyeball outward, and Cranial Nerve VIII (Acoustic) deals with hearing and balance.

Question 103.
Which of the following is the priority intervention for a child with epiglottitis?
(a) Providing oxygen by nasal cannula 
(b) Administering antibiotics 
(c) Assisting with intubation 
(d) Monitoring for dysrhythmias
Answer:
(c) Assisting with intubation 

Nursing Process: Intervention/Respiratory 

Rationale: 
Because children are at high risk for developing abrupt airway obstruction, the most important intervention for a child with epiglottitis is airway management. Intubation should be performed as soon as possible in a controlled environment. Children need supplemental oxygen, but most are so anxious that they will not allow nasal cannula to stay in place. Provide humidified “blow-by” oxygen administered by the parent, if possible. The child needs antibiotics; however, the priority is airway management. The most common rhythm in this patient is sinus tachycardia related to compensation and, although important, cardiac monitoring is not a priority.

Question 104.
Which of the following would indicate treatment for pertussis (whooping cough) has been effective?
(a) Resolution of characteristic “whooping" cough and fever
(b) Completion of the prescribed antibiotic treatment 
(c) Negative nasopharyngeal swap for Bordetella pertussis
(d) Negative reading of chest radiograph
Answer:
(c) Negative nasopharyngeal swap for Bordetella pertussis

Nursing Process: Evaluation/Communicable 

Rationale: 
A negative swab is the only definitive evidence that treatment has been effective. Despite resolution of fever and cough, pertussis infection may still be present in the body. Pertussis requires an extensive course of antibiotics, often up to 3 weeks. Pertussis is not detected on a chest radiograph.

Question 105.
A patient is brought to the emergency department 15 minutes after ingesting a full bottle of the tricyclic antidepressant amitriptyline (Elavil). Which of the following interventions would NOT be utilized in this scenario?
(a) Gastric lavage 
(b) Syrup of ipecac 
(c) Activated charcoal 
(d) Electrocardiogram (ECG)
Answer:
(b) Syrup of ipecac 

Nursing Process: Intervention/Toxicology 

Rationale: 
Syrup of ipecac is contraindicated in tricyclic antidepressant overdose. Because rapid deterioration with cardiovascular collapse and seizures can occur, inducing emesis may lead to airway compromise from aspiration. Gastric lavage could be ordered with endotracheal intubation with proper cuff inflation and mechanical ventilation. Administration of activated charcoal may be delayed. A baseline ECG may be ordered. The patient should be placed on a cardiac monitor because dysrhythmias and cardiac conduction delays are common.

Question 106.
A 1-year-old girl has experienced a febrile seizure. Which of the following statements made by the parents would indicate that they understood the discharge instructions regarding temperature control?
(a) “We will use alcohol baths if her temperature gets too high.”
(b) “We will keep her temperature down with tepid sponge baths and,acetaminophen (Tylenol).”
(c) “We will give herhhe phenobarbital when the temperature is above 101° F (38.3° C).”
(d) “We will use ice baths if her temperature goes up and we cannot get it to come down.”
Answer:
(b) “We will keep her temperature down with tepid sponge baths and,acetaminophen (Tylenol).”

Nursing Process: Evaluation/Neurologic 

Rationale: 
Between 25% and 30% of children who have suffered a febrile seizure may have reoccurrences. Keeping the temperature from increasing rapidly may contribute to the prevention of febrile seizures. Tepid sponge bath, administering antipyretics, and increasing fluid intake during febrile illnesses are key to preventing febrile seizures. An ice bath is too cool to bring the temperature down and the temperature should be brought down slowly by using tepid water between 60° F to 100° F (16° C to 38° C). Alcohol baths was an accepted form of temperature control in years past, but it was then realized that the alcohol could be absorbed through the skin causing alcohol poisoning. Phenobarbital does not affect temperature.

Question 107.
Which of the following is the best treatment for high-altitude pulmonary edema (HAPE)?
(a) Acclimatization 
(b) Antibiotics 
(c) Decrease in altitude 
(d) No specific treatment exists
Answer:
(c) Decrease in altitude 

Nursing Process: Intervention/Respiratory 

Rationale: 
A decrease in altitude is the best therapy for high-altitude pulmonary edema (HAPE) because it allows the body to initiate “self-correction” of many altitude-related physiologic processes, but acclimatization will rarely be sufficient without adjunctive therapy. Getting “down off the mountain” is the most beneficial treatment option along with providing oxygen to the patient. The mechanisms of HAPE are not borne by bacteria and thus are not treated as pneumonia. There are several treatments that can be used for high-altitude sickness.

Question 108.
A pediatric patient is unstable with poor perfusion, hypotension, and supraventricular tachycardia with a rate of 300 beats/minute. Immediate treatment would include which of the following?
(a) Administer adenosine intravenously using the port closest to the infusion site.
(b) Apply ice to the child’s face for 10-15 seconds.
(c) If the child is older, consider vagal maneuvers, such as coughing.
(d) Initiate synchronized cardioversion with 0.5 to 1 J/kg.
Answer:
(d) Initiate synchronized cardioversion with 0.5 to 1 J/kg.

Nursing Process: Intervention/Cardiovascular 

Rationale: 
Initiating synchronized cardioversion with 0.5 to 1 J/kg is initial treatment for unstable infants or children with supraventricular tachycardia. The patient in this scenario is hypotensive and has evidence of poor perfusion. Adenosine, application of ice to the face, and vagal maneuvers are attempted in children (and adults) who are hemodynamically stable.

Question 109.
An infant with a high-pitched cry, irritability, and fever is being prepped for a lumbar puncture (LP). Which of the following is an appropriate position for this patient during this procedure?
(a) Lateral with knees to chest and chin to chest 
(b) Lateral with legs extended and arms above the head
(c) Placing the patient in the prone position 
(d) Placing the patient in the supine position
Answer:
(a) Lateral with knees to chest and chin to chest 

Nursing Process: Intervention/Neurologic 

Rationale: 
Optimal positioning for a lumbar puncture in an infant is sitting upright or on their side with knees flexed and chin to chest. Older children or adults may be sitting on the side of the bed leaning over a bedside table. A prone position is not appropriate and the supine position would not provide access to the spinal area. The child or infant would have to be in a curled position in order to access the proper location for needle insertion.

Question 110.
A patient was involved in a fire inside a backyard shed and sustained deep partial-thickness burns to his face, head, and neck with singed nasal hair. He arrives with a hoarse voice. Which of the following is the priority nursing management for this patient’s airway?
(a) Deliver high-flow oxygen by rebreather mask 
(b) Monitor for increasing hoarseness of voice 
(c) Prepare for emergent intubation 
(d) Obtain equipment for emergency cricothyrotomy
Answer:
(c) Prepare for emergent intubation 

Nursing Process: Intervention/Respiratory 

Rationale: 
The priority for inhalation burn injury is to secure the airway with intubation. Burns of the face may indicate burns to the large and small airways. Although they initially appear stable, a burn will quickly swell and loss of the airway can occur rapidly. Waiting for the situation to worsen may delay intubation to the point at which intubation or even emergency cricothyrotomy is very difficult or impossible. Delivery of high-flow oxygen is appropriate but a rebreather mask does not secure an airway.

Question 111.
Which of the following eye complaints stated by a patient does the triage nurse recognize as emergent?
(a) Facial numbness and inability to look upward 
(b) Bloody appearance to the sclera 
(c) Perception of five to six floaters in the eye 
(d) Pain on the surface of the eye and excessive tearing
Answer:
(a) Facial numbness and inability to look upward 

Nursing Process: Analysis/Maxillofacial/Ocular 

Rationale: 
Facial numbness and inability to look upward are consistent with fracture to the orbital floor, also referred to as a blow-out fracture. The signs and symptoms are consistent with entrapment of extra-ocular muscles and the infraorbital nerve indicating a blow-out fracture. Subconjunctival hemorrhage results in bloody appearance of the sclera and is typically a benign uncomplicated presentation. Floaters in the eye may be seen with retinal detachment, yet when the patient can count the number of floaters, it is usually benign and not associated with retinal hemorrhage. Corneal abrasion results in significant eye irritation and pain with excessive tearing, yet is not considered an emergent presentation.

Question 112.
A patient is treated for a cholinergic exposure. Which of the following manifestations would indicate successful treatment?
(a) Miosis 
(b) Dry skin 
(c) Tachycardia
(d) Hypotension
Answer:
(b) Dry skin

Nursing Process: Evaluation/Toxicology

Rationale: 
Drying of the skin would be an indication that the cholinergic toxicity effect has been resolved. This toxidrome often causes lability, as either elevated or decreased, heart rate, respiration, and blood pressure, and is not known to directly change body temperature. Miosis is a symptom of cholinergic exposure; therefore, its presence would not indicate successful treatment. Tachycardia and hypotension may be symptoms of cho-linergic crisis; however, the treatment of cholinergic exposure would not intentionally create an abnormally high heart rate or an abnormally low blood pressure. Tachy-cardia and hypotension in this case would indicate that the patient was overtreated and a new problem, potentially an anticholinergic crisis, was created.

Question 113.
A patient with a history of poor dental hygiene and recent completion of chemotherapy presents with fever, mouth pain, swelling and bleeding to the gums, and malodorous breath. Which of the following actions would NOT be appropriate?
(a) Initiate dental consult 
(b) Suction the oropharynx 
(c) Intravenous access 
(d) Antibiotic administration
Answer:
(b) Suction the oropharynx 

Nursing Process: Intervention/Maxillofacial/Ocular 

Rationale: 
Airway compromise is not an expected finding and there is no indication that the airway is not patent, therefore suctioning is not indicated. Vincent’s angina, also referred to as acute necrotizing ulcerative gingivitis or trench mouth, is a bacterial infection of the gums. History typically includes immunosuppression, malnourishment, and poor dental hygiene. Classic presentation of Vincent’s angina includes bleeding, painful, swollen gums, fever, halitosis, and gray pseudomembranous ulcers on the pharynx. Intravenous access should be obtained for specimen collection, intravenous fluids, and antibiotic administration. The patient should be seen by a dentist for definitive management.

Question 114.
A tennis player presents at triage with a swollen and painful elbow joint. The emergency nurse suspects which of the following types of joint effusion?
(a) Septic arthritis 
(b) Gout
(c) Blood
(d) Bursitis
Answer:
(d) Bursitis

Nursing Process: Assessment/Orthopedic 

Rationale: 
Bursitis is an inflammation of the bursa sac of a joint from overuse. Blood in the joint occurs with trauma or surgery. Gout arises from an alteration in the production of uric acid. Septic arthritis is sudden in onset and occurs from bacteria entering the joint through the bloodstream, tissue, or a puncture wound.

Question 115.
A patient comes to the emergency department with complaints of burning and itching pain and intermittent numbness in the palm of the hand. The patient reports that it is usually worse upon awakening in the morning. The emergency nurse notes decreased grip strength to the affected hand. Which of the following is the nerve most often responsible for this problem?
(a) Ulnar 
(b) Median 
(c) Peroneal 
(d) Radial
Answer:
(b) Median 

Nursing Process: Analysis/Orthopedic 

Rationale: 
The median nerve is responsible for movement of the small muscles of the hand and sensation in the palm. This is the nerve involved in carpal tunnel syndrome. This nerve runs through the middle of the wrist into the hand. The space available for it in the carpal tunnel becomes minimized and symptoms then appear. The ulnar nerve allows for abduction of the fingers and supplies sensation to the little finger. The radial nerve provides the ability to extend the thumb and delivers sensation to the dorsum of the thumb. Both of these nerves can be involved in carpal tunnel syndrome, but are not the cause. The peroneal nerve is located in the foot and causes extension of the foot and great toe and sensation to the first web space.

Question 116.
A 4-month-old presents with decreased feeding and increased somnolence. He has had two episodes of vomiting in the last 3 hours. Vital signs are as follows:
Blood pressure—108/38 mm Hg 
Pulse—66 beats/minute 
Respirations—30 breaths/minute 
Temperature—97°iF (36.1° C)

Which of the following is the most likely cause of these symptoms?
(a) Dehydration 
(b) Increased intracranial pressure 
(c) Autonomic dysreflexia 
(d) Increased intra-abdominal pressure
Answer:
(b) Increased intracranial pressure 

Nursing Process: Analysis/Neurologic 

Rationale: 
Increased intracranial pressure produces observable signs and symptoms depending on the stage of increased pressure. Early signs include headache, nausea and vomiting, altered level of consciousness, and drowsiness. Late signs include increased systolic blood pressure, bradycardia, widening pulse pressures, and dilated nonreactive pupils. Hypothermia, bradycardia, and a widened pulse pressure are indicative of increased intracranial pressure. Two episodes of vomiting in 3 hours should not cause these symptoms. Autonomic dysreflexia is a hypertensive emergency and occurs in patients who have a history of spinal cord injuries. There is no indication in the stem of the question to indicate increased intra-abdominal pressure.

Question 117.
A patient has profuse bleeding from the nose that has persisted despite application of firm pressure to the nostrils. Which of the following diagnostic evaluations is the priority test?
(a) Activated partial thromboplastin time (aPTT)
(b) Complete blood count (CBC) and prothrombin time (PT)
(c) International normalized ratio (INR)
(d) Hematocrit count and type and crossmatch
Answer:
(d) Hematocrit count and type and crossmatch

Nursing Process: Analysis/Maxillofacial/Ocular 

Rationale: 
The priority is to maintain a patent airway and ensure hemodynamic stability. Monitoring the amount of blood loss and preparing for blood replacement are interventions that meet those priorities. Type and crossmatch are essential to prepare for blood volume replacement, should it be needed. Complete blood count (CBC), international normalized ratio (INR), partial Thromboplastin Time (aPTT), and protime (PT) are all important to determine clotting status and blood loss; however, the hematocrit and type and crossmatch are the priority tests.

Question 118.
Thirty minutes after a patient is admitted to the emergency department, the emergency nurse performs a repeat neurologic examination. The patient does not follow commands, but after several attempts by the nurse to apply noxious stimuli, he opens his eyes and moves the nurse’s hand. The patient utters a one-word response to the nurse. Which of the following is the correct Glasgow Coma Scale for this patient?
(a) 5 
(b) 7 
(c) 10 
(d) 12
Answer:
(c) 10 

Nursing Process: Evaluation/Neurologic 

Rationale: 
This patient is given 5 points for purposeful movement to pain (motor), 3 points for inappropriate words (verbal), and 2 points for eye opening in response to painful stimuli. The total score is 10. Remember! The lowest score on a Glasgow Coma Scale is 3—not 0! Highest potential scoring is IS.

Question 119.
Which of the following conditions is manifested by frequent sustained vomiting, often resulting in dehydration and weight loss of the pregnant patient?
(a) Cyclical vomiting 
(b) Gastroenteritis 
(c) Hyperemesis gravidarum 
(d) Ulcerative colitis
Answer:
(c) Hyperemesis gravidarum 

Nursing Process: Assessment/GU/GYN/OB 

Rationale: 
Hyperemesis gravidarum is more extreme than morning sickness and is experienced by 70% to 80% of women early in their pregnancy. This condition often continues throughout pregnancy and is thought to be caused by the rise of hormone levels. It may lead to hospitalization for rehydration. Cyclical vomiting occurs as sudden and repeated episodes of vomiting but is not associated with pregnancy. Gastroenteritis is inflammation of the stomach and intestine and ulcerative colitis is inflammation of the colon with ulcers.

Question 120.
When assessing a patient with an eyelid laceration, the emergency nurse concludes that the patient has a deep laceration with injury to the levator muscle due to which of the following alterations?
(a) Inability to close the eyelid 
(b) Inability to open the eyelid 
(c) Bleeding to the lid 
(d) Visual disturbance
Answer:
(b) Inability to open the eyelid 

Nursing Process: Assessment/Maxillofacial/Ocular 

Rationale: 
Ptosis occurs with eyelid lacerations affecting the levator muscle that is located under the upper lid, above the globe. This muscle is responsible for raising the upper lid. Bleeding may occur with any laceration and should be controlled. Visual disturbances may occur with eyelid lacerations with concurrent injury such as hyphema or globe disruption.

Question 121.
Which of the following statements made by a patient being discharged with a tick bite indicates the need for further instructions?
(a) “I need to get antibiotics every time 1 find a tick walking on me.”
(b) “When I go walking I will wear my pants tucked into my socks.”
(c) “To remove a tick—grab the head with tweezers and twist it off.”
(d) “I will use tick repellant when walking in areas with known ticks.”
Answer:
(a) “I need to get antibiotics every time 1 find a tick walking on me.”

Nursing Process: Evaluation/Environmental 

Rationale: 
A walking tick has not latched on, sucked blood, or transmitted a tick-borne disease to the patient. Additionally, most patients with a tick exposure will not be prophylactically treated, but the provider will treat based on disease risk in area and type of disease risk. It is appropriate to tuck pants legs into socks to keep ticks and other insects off of the ankle areas. Removing ticks can be accomplished by using tweezers and a twisting motion and tick repellant would be correct.

Question 122.
While caring for a patient with a ventriculostomy, the nurse notices that the intracranial pressure (ICP) reading is 30 mm Hg. The nurse assesses the patient and the ICP monitor and determines that the drain is open. Which of the following would be the appropriate immediate intervention for this patient?
(a) Move the head from a rotated position to the midline.
(b) Lower the head of the bed to the Trendelenburg position.
(c) Close the stopcock on the ventriculostomy.
(d) Elevate the head of the bed to high Fowler’s position.
Answer:
(a) Move the head from a rotated position to the midline.

Nursing Process: Intervention/Neurologic 

Rationale: 
A rotated head position will prevent venous outflow via the jugular veins and contribute to increased intracranial pressure (ICP). The head of the bed should be maintained at 30 degrees, and hyperextension, flexion, and rotation of the head should be avoided. Placing the patient in Trendelenburg by lowering the head of the bed would increase the pressure on the brain. Closing the stopcock on the ventriculostomy causes the ICP to rise because there is no longer an outlet for the cerebrospinal fluid (CSF).

Question 123.
A patient is diagnosed with a knee dislocation after a sporting event. The emergency nurse should consider which of the following additional injuries that is common with this primary injury?
(a) Fibula fracture 
(b) Saphenous vein injury 
(c) Popliteal artery injury 
(d) Tibial nerve injury
Answer:
(c) Popliteal artery injury 

Nursing Process: Assessment/Orthopedic 

Rationale: 
Popliteal artery injury is a frequent and significant high-risk complication with a dislocated knee. All patients including those who relocate spontaneously before arrival to the emergency department should be assessed for this event. Some can maintain pulse for a time due to collateral flow. Fibula fracture and tibial nerve injuries are not usually associated with knee dislocation. The saphenous vein is in the lower leg away from the knee.

Question 124.
Postpartum hemorrhage can occur immediately after delivery or can be delayed by as much as 6 weeks. Which of the following is NOT a cause of postpartum hemorrhage?
(a) Retained products of conception 
(b) Vaginal or cervical tear 
(c) Failure of uterus to contract to normal 
(d) Amniotic fluid embolism
Answer:
(c) Popliteal artery injury 

Nursing Process: Analysis/GU/GYN/OB 

Rationale: 
Postpartum hemorrhage is defined as blood loss greater than 500 mL and is a common complication of labor and delivery. Amniotic fluid embolism, a complication experienced by the mother, is caused when amniotic fluid leaks into the mother’s venous circulation during labor and delivery. It does not cause postpartum hemorrhage. Retained products of conception or placental fragments can interfere with involution or return of the uterus to normal size. Vaginal or cervical tears can be a cause of postpartum bleeding. 

Question 125.
A patient presents after being hit in the face with a baseball. The patient states he has “bloody vision” and assessment reveals decreased visual acuity. What other assessment data confirms the presence of a hyphema?
(a) Patient describes perception of a curtain coming down over his eye
(b) Visualization of blood covering the lower half of the iris
(c) Limitation in extraocular eye movements 
(d) Severe pain when blinking the eye
Answer:
(b) Visualization of blood covering the lower half of the iris

Nursing Process: Assessment/Maxillofacial/Ocular 

Rationale: 
Visualization of blood in the anterior chamber of the eye is the definition of a hyphema. Hyphema may occur secondary to blunt or penetrating trauma, and any portion of the anterior chamber of the eye may be affected, evidenced by a blood fluid line across the iris or blacked-out appearance in an eight-ball hyphema. The patient will experience blurry vision, blood-tinged vision, pain, and decreased visual acuity. Retinal detachment gives the perception of floaters, flashing lights, or a veil or curtain across a visual field. Orbital fractures, leading to entrapment of the extraocular muscles results in the inability to move the eye. Corneal abrasion results in pain with lid or globe movement.

Question 126.
Which of the following tests is frequently used to diagnose myasthenia gravis?
(a) Lumbar puncture 
(b) Tensilon test 
(c) Allen’s test
(d) Magnetic resonance imaging (MRI)
Answer:
(b) Tensilon test

Nursing Process: Analysis/Neurologic 

Rationale: 
In the Tensilon test, edrophonium (Tensilon) is administered by intravenous infusion to a patient exhibiting signs of muscle weakness. Significant improvement, lasting approximately 4 to 5 minutes, in the patient’s muscle tone indicates a positive diagnosis for myasthenia gravis. A lumbar puncture (LP) is frequently performed to assist in diagnosing meningitis. Allen’s test is performed to evaluate the circulatory function of the ulnar artery before obtaining arterial blood gases ABGs to verify collateral circulation before accessing the radial artery. An MRI is effective in detecting degenerative central nervous system diseases, malignant tumors, and oxygen-deprived tissue, but none of these findings are associated with myasthenia gravis.

Question 127.
When administering intravenous magnesium, the emergency nurse should take which of the following actions?
(a) Administer the infusion slowly 
(b) Dilute the solution with normal saline only 
(c) Administer narcotics at routine dose strength 
(d) Monitor pulse and blood pressure every 4 hours
Answer:
(a) Administer the infusion slowly 

Nursing Process: Intervention/Medical 

Rationale: 
Magnesium sulfate must be infused slowly at a rate not to exceed 125 mg/kg/hour to avoid potential cardiac or respiratory arrest. Normal saline or 5% dextrose should be used to dilute the infusion. Caution should be used when administering CNS depressants such as narcotics and barbiturates because they potentiate the central nervous system depressant effect of magnesium. Patients being treated with intravenous magnesium sulfate should be placed on continuous cardiac/respiratory monitoring.

Question 128.
Which of the following is NOT a normal physiologic change that occurs in pregnancy?
(a) Resting heart rate increases 
(b) Peripheral resistance increases 
(c) Circulating plasma increases 
(d) Oxygen consumption increases
Answer:
(b) Peripheral resistance increases 

Nursing Process: Assessment/GU/GYN/OB 

Rationale: 
Peripheral resistance decreases during pregnancy, causing a slight decrease in systolic and diastolic blood pressure. The resting heart rate actually increases 10 to 20 beats/minute and the circulating blood volume increases by 30% to 50%. Respirations increase to help accommodate for the increased oxygen consumption during pregnancy.

Question 129.
A patient receiving pharmacologic medications for combativeness associated with a head injury responds to noxious stimuli only. Which of the following scores on the Ramsay Score for Sedation (RASS) would be documented?
(a) 1 
(b) 3
(c) 5 
(d) 15
Answer:
(c) 5 

Nursing Process: Evaluation/Neurologic 

Rationale: 
The modified Ramsay Score for Sedation measures the level of sedation achieved with pharmacologic agents. A Ramsay score of 5 suggests that the patient responds only to noxious stimuli. A patient who is anxious, agitated, or restless has a Ramsay score of 1. A patient who is cooperative, tranquil, and oriented has a score of 2. A patient who responds to voice and verbal commands has a Ramsay score of 3. A patient who responds to gentle shaking scores a 4. A patient who shows no response to noxious stimuli is considered a 6 on the scale. The scale ranges from 1 to 6 only.

Question 130.
As part of the sexual assault examination, which of the following should be done with the victim’s clothing?
(a) Place it in a paper bag and seal it with evidence tape.
(b) Return it to the patient after examining it.
(c) Place it in a plastic bag and seal it with paper tape.
(d) Shake it out carefully to look for hidden evidence.
Answer:
(a) Place it in a paper bag and seal it with evidence tape.

Nursing Process: Intervention/GU/GYN/OB 

Rationale: 
Clothing that was worn by the patient and obtained during the sexual assault examination should be placed in a paper bag and secured with evidence tape to ensure that no tampering occurs. When performing a sexual assault examination and collecting the clothing, each piece of clothing should be placed in a separate paper bag. Also, the patient should stand on a sheet and then that sheet should be also be seat as evidence. The emergency nurse should also put their name or initials across the fold of the bag to assist with knowledge of non tampering as well. 

The patient’s clothing should be carefully removed, but not shaken out; microscopic evidence may be lost. All clothing should be given to the police; it is their responsibility to determine if evidence is present. Clothing should not be placed in plastic bags, which can cause mildew and moisture retention, both of which can cause loss of evidence. All evidence collected should be labeled with the victim’s name, site of collection, date and time of collection, and the name of the person collecting the evidence.

Question 131.
Which of the following is a potential complication after manipulation of a long-bone fracture?
(a) Deep vein thrombosis
(b) Pulmonary embolism
(c) Acute respiratory distress syndrome 
(d) Fat embolism
Answer:
(d) Fat embolism

Nursing Process: Analysis/Orthopedic 

Rationale: 
Fat embolism is a potential complication when long bone fractures are manipulated. This complication may occur within 12 hours. This is why immediate immobilization is so important. Deep vein thrombosis develops from immobility, which may then lead to pulmonary embolism. This can then progress to acute respiratory distress syndrome.

Question 132. 
A patient has the appearance of bright red blood to the lateral portion of the sclera. The patient states he noticed the redness after continuous harsh coughing yet denies recent trauma and pain. The emergency nurse suspects this patient will be diagnosed with which of the following?
(a) Retinal hemorrhage 
(b) Ultraviolet keratitis 
(c) Subconjunctival hemorrhage 
(d) Eight-ball hyphema    
Answer:
(c) Subconjunctival hemorrhage 

Nursing Process: Assessment/Maxillofacial/Ocular 

Rationale: 
A subconjunctival hemorrhage is a benign condition that occurs when blood vessels of the conjunctiva rupture and blood is trapped between the sub-conjunctiva and the sclera. Some cases are idiopathic, yet it frequently occurs due to increased pressure to the area secondary to coughing, straining, forceful vomiting, or vigorous rubbing of the eye. Subconjunctival hemorrhage occurs suddenly, and other than the appearance, the patient is usually asymptomatic. Hyphema indicates blood in the anterior chamber of the eye resulting from trauma. An eight-ball hyphema occurs when the entire anterior chamber is covered in blood. Retinal hemorrhage occurs in association with other eye injuries and/or head trauma. Both hyphema and retinal hemorrhage results in visual disturbances. Ultraviolet keratitis is a type of corneal burn that may have delayed onset of symptom from the time of the exposure to ultraviolet light.

Question 133.
Which of the following would be the priority action if an ischemic stroke patient receiving tissue plasminogen activator (TPA) infusion begins to vomit bright red blood?
(a) Notify the physician 
(b) Place a nasogastric tube
(c) Decrease the infusion 
(d) Stop the infusion
Answer:
(d) Stop the infusion

Nursing Process: Intervention/Neurologic 

Rationale: 
Tissue plasminogen activator (TPA) is a fibrinolytic medication that decreases the patient’s ability to clot. The infusion should be stopped immediately. While a patient is receiving TPA, all invasive procedures should be avoided due to the increased risk of bleeding; therefore, a nasogastric tube should not be placed. The physician should be notified, but the priority is to stop the infusion.

Question 134.
A patient comes to the emergency department complaining of a nosebleed, which began 2 hours before her arrival, and has not subsided, despite direct pressure. She has generalized ecchymosis and states she has a history of idiopathic thrombocytopenia (ITP). Replacement therapy is indicated based on the diagnostic workup. Which of the following is the appropriate treatment?
(a) Desmopressin (DDAVP)
(b) IVIg (intravenous immunoglobulin)
(c) Thrombin injection 
(d) Factor VIII
Answer:
(b) IVIg (intravenous immunoglobulin)

Nursing Process: Intervention/Medical 

Rationale: 
In the patient with known idiopathic thrombocytopenia (ITP), an intravenous infusion of immunoglobulin is a first-line intervention, because it causes a rapid rise in the platelet levels. Platelet transfusion can also be considered if the count is less than 50,000 and in the presence of severe hemorrhage. Desmopressin is a synthetic version of vasopressin that increases the levels of factor VIIIc in the treatment of mild-to-moderate hemophilia. Factor VIII would be utilized in patients with hemophilia A. Thrombin causes blood coagulation by converting fibrinogen to fibrin. Thrombin is indicated for epistaxis but is not a treatment for ITP.

Question 135.
Which of the following vaginal infections does NOT require treatment of sexual partners?
(a) Neisseria gonorrhoeae
(b) Candida albicans 
(c) Trichomonas vaginalis 
(d) Chlamydia trachomatis
Answer:
(b) Candida albicans 

Nursing Process: Intervention/GU/GYN/OB 

Rationale: 
Candida albicans is a yeast (fungal infection) treated with Mycostatin (nystatin) and does not require sexual partner treatment. Neisseria gonorrhoeae, Trichomonas vaginalis, and Chlamydia trachomatis all are sexually transmitted diseases that necessitate partner treatment and thorough patient education.

Question 136.
A patient presents with unilateral painless loss of vision and is being evaluated for central retinal artery occlusion. Priority intervention by the emergency nurse includes which of the following?
(a) Digital ocular massage 
(b) Patch the affected eye 
(c) Facilitate mild hyperventilation 
(d) Assist the patient to supine position
Answer:
(d) Assist the patient to supine position

Nursing Process: Intervention/Maxillofacial/Ocular 

Rationale: 
Central retinal artery occlusion results from an embolus lodged in the retinal artery. Vision loss is sudden and painless. Priority interventions are geared toward restoring circulation within 90 minutes of symptom onset to prevent permanent blindness. Supine position optimizes circulation. A temporary measure of having the patient rebreathe carbon dioxide (brown bag or administration of carbogen gas) may facilitate mild vasodilation. Ocular massage should be reserved for a provider and may increase circulation or dislodge a clot. An eye patch is indicated in conditions in which eye movement is prohibited to promote healing and decrease pain. Hyperventilation will result in loss of carbon dioxide that may result in vasoconstriction.

Question 137.
A patient presents to triage several hours after having a cast placed complaining of severe pain uncontrolled by pain medication. Which of the following would be the priority intervention for this patient?
(a) Provide pain medication
(b) Ultrasound for deep vein thrombosis 
(c) Bivalve the cast immediately 
(d) Check compartmental pressure
Answer:
(c) Bivalve the cast immediately 

Nursing Process: Intervention/Orthopedic 

Rationale: 
The most important priority intervention for this patient is to bivalve the cast. Nothing can be' done until the area can be visualized. Sometimes just removing the cast can take care of the pain. Compartment syndrome is a major concern, but the pressure cannot be checked until the cast is removed. This can be caused by an external force such as a cast, and pain disproportionate to injury is an indication of this complication. Deep vein thrombus is painful but not disproportionate. Pain control may be an issue, but again the hallmark symptom in this scenario is the report of disproportionate pain to injury.

Question 138.
Goal-directed Initial resuscitation measures for septic shock include which of the following?
(a) Treating a state of hypoperfusion 
(b) Decreasing systemic vascular resistance (SVR)
(c) Administrating epinephrine subcutaneously 
(d) Utilizing intravenous diuretic therapy
Answer:
(a) Treating a state of hypoperfusion 

Nursing Process: Intervention/Medical 

Rationale: 
Because septic shock is associated with a high mortality rate due to a state of severe hypoperfusion, early goal-directed resuscitation measures include treating the state of hypoperfusion. This includes fluid boluses, increasing the systemic vascular resistance (SVR) with vasopressor agents, and/or administering packed red blood cells (PRBCs) if needed. These measures will decrease the risk of end organ damage often seen in cases of septic shock. Systemic vascular resistance is lowered in septic shock and treatment is aimed at increasing resistance. International guidelines recommend dopamine or norepinephrine as first-line vasopressor agents in septic shock, whereas epinephrine and vasopressin are considered second-line agents. The effect of vasopressors will improve renal output; thus, there is no indication, for diuretic therapy.

Question 139.
Which of the following does the emergency nurse expect to be in the treatment plan for a patient with Meniere’s disease, yet not for labyrinthitis?
(a) Administration of antiemetic medication 
(b) Instructions to change positions slowly 
(c) Instructions to avoid operation of heavy machinery 
(d) Administration of diuretic medication
Answer:
(d) Administration of diuretic medication

Nursing Process: Intervention/Maxillofacial/Ocular 

Rationale: 
Diuretics and low sodium diet are part of the treatment plan for the patient with Meniere’s disease to decrease the fluid and pressure build up in the endolymphatic system. Labyrinthitis is due to viral or bacterial infections leading to inflammation of the labyrinth. Nausea and vertigo are experienced in both disorders. Hence, the need for antiemetics and instructions to manage vertigo and maintain safety.

Question 140.
Which of the following statements made by a patient being discharged with a new prescription for phenytoin (Dilantin) indicates that the patient understands their instructions?
(a) “I know that if I miss a routine dose I cannot easily make it up.”
(b) “I am glad to know that I won’t have to have routine lab tests.”
(c) “I am aware that if 1 stop taking this medication I am at risk for status epilepticus.”
(d) “It’s good that I don’t have to worry about a bunch of adverse effects from this drug.”
Answer:
(c) “lam aware that if 1 stop taking this medication I am at risk for status epilepticus.”

Nursing Process: Intervention/Maxillofacial/Ocular 

Rationale: 
Diuretics and low sodium diet are part of the treatment plan for the patient with Meniere’s disease to decrease the fluid and pressure buildup in the endolymphatic system. Labyrinthitis is due to viral or bacterial infections leading to inflammation of the labyrinth. Nausea and vertigo are experienced in both disorders. Hence, the need for antiemetics and instructions to manage vertigo and maintain safety.

Question 141.
Which of the following statements made by a patient diagnosed with Vincent’s angina indicates the need for further instruction?
(a) “I will eat a well-balanced diet.”
(b) “I know to take all the antibiotics as directed.”
(c) “I should rinse my mouth with antiseptic mouthwash.”
(d) “I will brush my teeth with a hard-bristle toothbrush.”
Answer:
(d) “I will brush my teeth with a hard-bristle toothbrush.”

Nursing Process: Evaluation/Maxillofacial/Ocular 

Rationale: 
Vincent’s angina is a bacterial infection of the gums resulting in bleeding, painful, swollen gums. Once brushing can be tolerated, a soft-bristle toothbrush should be used or the patient can gently wipe the gums. The patient should be instructed to eat nutritious food, take antibiotics as prescribed, and rinse the mouth with an antiseptic mouthwash in the acute phase of the infection.

Question 142.
A patient with an amputation of the hand from being caught in a machine at work presents with ongoing bleeding despite direct pressure and elevation of the extremity. Which of the following is the next appropriate interventional step?
(a) Apply pressure dressing 
(b) Insert an intravenous catheter 
(c) Notify the physician 
(d) Apply a tourniquet
Answer:
(d) Apply a tourniquet

Nursing Process: Intervention/Orthopedic 

Rationale: 
Controlling the hemorrhage is the highest priority. Application of a tourniquet would be the next step because direct pressure and elevation of the extremity has not stopped the bleeding. Application of a pressure dressing would most likely not help because direct pressure has not worked. Starting an intravenous catheter and notifying the physician are important, but hemorrhage control is the priority.

Question 143.
A patient reports acute onset of loss of partial vision described as a cloudy veil over the top portion of the eye. The patient denies pain. The emergency nurse prepares for which of the following diagnostic evaluations that will confirm the diagnosis?
(a) Tonometry for intraocular pressure measurement 
(b) Fluorescein stain for examination of the cornea 
(c) Pupil dilation for fundal examination 
(d) Computed tomography (CT) of the orbits
Answer:
(c) Pupil dilation for fundal examination 

Nursing Process: Analysis/Maxillofacial/Ocular 

Rationale: 
Painless loss of vision accompanied by the perception of floaters, flashing lights, cloudy smoky vision, or a veil or curtain over the vision are classic presentations for retinal detachment. Retinal detachment is separation of the layers of the retinal and subsequent fluid or blood pooling between the retinal layers. Retinal detachment can occur spontaneously or secondary to trauma. The condition is diagnosed by a dilated posterior eye examination of the fundus. Tonometry is indicated for glaucoma and iritis. Fluorescein stain is indicated for assessment of corneal irregularities such as abrasions or ulcerations. Computed tomography (CT) is indicated in orbital fracture, sinusitis, and associated facial trauma.

Question 144.
A teenaged boy comes to the emergency department after waking with severe pain to his left testicle. Examination reveals the following vital signs:
Blood pressure—110/72 mm Hg
Pulse—120 beats/minute 
Respirations—30 breaths/minute 
Pulse oximetry—98 % on room air 
Temperature—98.5° F (36.9° C)

His left testicle is slightly elevated and firm. Which of the following would be the most appropriate „ intervention?
(a) Send the patient for ultrasound.
(b) Apply ice packs to the scrotum.
(c) Prepare to transfuse blood products.
(d) Elevate scrotum to 45-degree angle.
Answer:
(a) Send the patient for ultrasound.

Nursing Process: Intervention/GU/GYN/OB 

Rationale: 
This patient has signs and symptoms of testicular torsion. Testicular torsion results from congenital maldevelopment between the testis and the posterior scrotal wall. This is an emergency situation and an emergent ultrasound must be done. Twisting of the spermatic cord compromises the circulation, causing severe pain that is not relieved by ice or elevation. There is no blood loss associated with testicular torsion, so blood products are not indicated.

Question 145.
Which of the following electrolyte abnormalities is commonly experienced by a patient in adrenal crisis?
(a) Hypocalcemia 
(b) Hypernatremia 
(c) Hyperglycemia 
(d) Hyperkalemia
Answer:
(d) Hyperkalemia

Nursing Process: Assessment/Medical 

Rationale: 
Potassium elevation occurs in adrenal crisis because of an inability to regulate aldosterone, resulting in sodium and water depletion and retention of potassium. These patients frequently have hyponatremia in conjunction with hyperkalemia. Patients with Addison’s disease also have low cortisol production, inhibiting the breakdown of sugar into glucose, resulting in hypoglycemia. Hypocalcemia is related to low levels of mineralocorticoids, unrelated to aldosterone production.

Question 146.
An immunocompromised patient presents to the emergency department on the advice of their primary physician based on which of the following physiologic criteria?
(a) Elevated neutrophil count 
(b) Wound with purulent drainage 
(c) Warm, red, swollen insect bite 
(d) Temperature >100.4° F (38° C)
Answer:
(d) Temperature >100.4° F (38° C)

Nursing Process: Assessment/Medical 

Rationale: 
The most significant indicator of infection in an immunocompromised person is fever. Thus, this population is instructed to seek medical care whenever the body temperature reaches 100.4° F (38° C). Immunocompromised patients become neutropenic (decreased neutrophils) and leukemic (decreased total white blood cell count). The body’s phagocytic response is suppressed because the body does not recognize the presence of an infection by typical symptoms such as heat, redness, swelling, and pus at the site of infection.

Question 147.
A trauma patient with a diagnosis of a ruptured bladder has two large-bore intravenous lines, oxygen, a nasogastric tube, and an indwelling urinary catheter in place. Initial vital signs are as follows:
Blood pressure—120/54 mm Hg 
Pulse—120 beats/minute 
Respirations—28 breaths/minute 
Pulse oximetry—95 % on room air 
Temperature—98.2° F (36.7° C)

Which of the following might indicate impending hypovolemic shock?
(a) Pulse of 100 beats/minute 
(b) Restlessness
(c) Blood pressure of 110/64 mm Hg 
(d) Request for pain relief
Answer:
(b) Restlessness

Nursing Process: Evaluation/GU/GYN/OB 

Rationale: 
Restlessness is typically the first sign of impending hypovolemic shock or hypoxia. A pulse rate of 100 beats/minute is actually a decrease compared with the original 120 beats/minute, and the blood pressure has not dropped significantly. Requests for pain relief are normal for a trauma patient.

Question 148.
A parent presents with their infant requesting a “rabies shot” because they saw a bat flying in the child’s bedroom. The emergency nurse would anticipate:
(a) reassuring the parent that unless a wound is found, there is no risk of rabies.
(b) administering Rabies Immune Globulin and first dose of Rabies vaccine.
(c) setting up appointments for the series of rabies injections twice a day for 21 days.
(d) initiating prophylactic intravenous antibiotics as soon as possible.
Answer:
(b) administering Rabies Immune Globulin and first dose of Rabies vaccine.

Nursing Process: Intervention/Environmental 

Rationale: 
Because the bite of a rabid bat is so small, difficult to find, generally unfelt during sleep, and the high risk that the bat could have rabies, the recommendation is that if a bat is seen in a room where someone was sleeping they should receive the rabies series. Initial treatment is with Rabies Immune Globulin (RIG) and the first dose of Rabies vaccine if the patient has not been vaccinated previously. Antibiotics will not help. Rabies vaccine is no longer administered twice a day for 21 days and there is a high risk for this patient per the CDC because this is a child. Other high-risk patients include someone found altered due to alcohol or drugs, the elderly, or sound sleepers.

Question 149.
Which of the following interventions is most appropriate for a patient with a pulmonary contusion? 
(a) Restrict intravenous fluid administration
(b) Provide supplemental humidified oxygen 
(c) Position the patient to facilitate breathing 
(d) Assist with removal of secretions
Answer:
(a) Restrict intravenous fluid administration

Nursing Process: Intervention/Respiratory 

Rationale: 
If the patient is not exhibiting symptoms of hypovolemic shock, intravenous fluids should be restricted during initial care. While providing supplemental oxygen, positioning the patient to facilitate breathing, and assisting with removal of secretions are all treatments for pulmonary contusion, limiting intravenous fluid administration is associated with the best outcome for the patient.

Question 150.
Which of the following is the most important treatment for the patient with tension pneumothorax? 
(a) Elevate the head of the patient’s bed.
(b) Administer 100% oxygen.
(c) Infuse intravenous normal saline slowly.
(d) Assist with needle decompression. 
Answer:
(d) Assist with needle decompression. 

Nursing Process: Intervention/Respiratory 

Rationale: 
All the options listed are important in the treatment of tension pneumothorax, but the most important is needle decompression. A 14-G needle is inserted into the second intercostal space at the midclavicular line on the affected side is appropriate. A chest tube insertion should follow needle decompression.

CEN Practice Tests:

• CEN Practice Test 1
• CEN Practice Test 2
• CEN Practice Test 3
• CEN Practice Test 4
• CEN Practice Test 5
• CEN Practice Test 6
• CEN Practice Test 7