CEN Sample Test 2 with Rationale

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

BCEN Sample Test 2 with Rationale

Question 1.
A 45-year-old patient arrives in the emergency department complaining of fever for the past 2 days. He is awake, alert, and oriented with the following vital signs:
Blood pressure—124/74 mm Hg 
Heart rate—120 beats/minute 
Respirations—22 breaths/minute 
Pulse oximetry—94% on room air 
Temperature—101.6° F (38.7° C)

He reports that he is HIV positive and taking antiviral medications. The emergency nurse should triage him at which acuity level using a 5-level system?
(a) Level 1 (resuscitation or life-threatening)
(b) Level 2 (high risk and/or emergent)
(c) Level 3 (urgent)
(d) Level 4/5 (nonurgent/nonemergent)
Answer:
(b) Level 2 (high risk and/or emergent)

Nursing Process: Assessment/Communicable 

Rationale: 
Human Immunodeficiency Virus (HIV) positive patients with a fever are at high risk for deterioration and should be prioritized to an immediate open bed. The patient requires a workup to determine the source of fever and should be protected from other patients who may have a communicable infectious condition. This patient is not unresponsive, apneic, or in need of any life-saving interventions upon arrival, thus does not meet criteria for a level 1 acuity. Level 3 patients require two or more resources according to the Emergency Severity Index (ESI) algorithm, but his immunocompromised condition escalates his acuity to level 2 Level 4 patients require only one resource and this patient will clearly need multiple resources to identify the source of, and treat, the fever. In a five-level system, level 5 requires no resources.

Question 2.
Which of the following parenteral solutions should be used in the initial treatment of intracellular fluid deficit of a patient with hyperosmolar hyperglycemic syndrome?
(a) DSW with 0.9% normal saline (NS)
(b) D5W with 0.45% normal saline (NS)
(c) 0.9% NS with 20 mEq potassium chloride 
(d) 0.9% normal saline (NS)
Answer:
(d) 0.9% normal saline (NS)

Nursing Process: Intervention/Medical 

Rationale: 
Fluid deficit can exceed 10 liters in Hyperglycemic Hyperosmolar Syndrome (HHS). Rapid rehydration with 0.9 normal saline is required to prevent circulatory collapse. Solutions containing dextrose are not indicated in the initial treatment of HHS but may be considered once serum glucose reaches 250 to 300 mg/ dL. Serum potassium levels are generally within normal limits initially but should be monitored as the serum glucose levels decrease. Supplemental potassium can be added as needed.

Question 3.
Which of the following is a gynecological/obstetric condition that must be considered as a potentially dangerous situation for every female presenting with abdominal pain during child-bearing years?
(a) Ectopic pregnancy 
(b) Ovarian cyst 
(c) Ovarian torsion 
(d) Dysmenorrhea
Answer:
(a) Ectopic pregnancy 

Nursing Process: Assessment/GU/GYN/OB 

Rationale: 
Ectopic pregnancy (pregnancy occurring outside of the uterus) usually manifests before 12 weeks gestation, produces pelvic pain, and shock if ruptured. It is considered a true emergency and is a major cause of maternal death. An ovarian cyst is a fluid-filled sac in the ovary that may be painful and is usually self-limiting but may develop hypovolemia when it ruptures. Ovarian torsion occurs when the ovary twists itself around the stalk that contains the blood vessels feeding the ovary and the fallopian tube. Pain is due to ischemia and requires surgical intervention. Dysmenorrhea is defined as painful menstruation in the absence of any other pelvic condition.

Question 4.
A patient complains of acute shortness of breath, frothy pink-tinged sputum, and chest pain. Crackles and wheezes are present. Past medical history includes diabetes, hypertension, and heart failure. The emergency nurse suspects which of the following disease processes?
(a) Pericardial tamponade
(b) Pneumothorax
(c) Pulmonary embolus
(d) Pulmonary edema
Answer:
(d) Pulmonary edema

Nursing Process: Assessment/Cardiovascular 

Rationale: 
The symptoms presented are typical of acute pulmonary edema related to heart failure. Pericardial tamponade has muffled heart sounds, distended neck veins, and hypotension (Beck’s triad). Breath sounds would be decreased on the affected side in a pneumo-thorax. Pulmonary embolus causes nonspecific signs, but dyspnea, tachypnea, syncope, and cyanosis are most common.

Question 5.
A patient has extensive burns to his head, face, neck, and chest with much of his hair, including his eyebrows, burned off from an ignited flammable liquid. He is conscious, breathing, and is in significant pain. He is noted to have a mildly hoarse voice. A baseline physical assessment has been completed. The most reliable additional assessment of the patient’s breathing status would include:
(a) arterial blood gases (ABGs).
(b) complete blood count (CBC).
(c) mixed venous blood gases.
(d) oxygen saturation monitoring.
Answer:
(a) arterial blood gases (ABGs).

Nursing Process: Assessment/Respiratory 

Rationale: 
Arterial blood gases (ABGs) provide a specific value for the PaO₂—a much more reliable number to ascertain oxygenation status. An oxygen saturation monitor does not differentiate among oxygen, carbon monoxide, or any other toxic substance bound to the hemoglobin. Mixed venous blood gases do not yield as useful information as an ABG. A complete blood count (CBC) will provide the hemoglobin value important in oxygen transport; however, the hemoglobin is usually reported in the ABG results.

Question 6.
The Joint Commission sentinel event alert related to preventing restraint deaths identified all of the following risks EXCEPT:
(a) placing a restrained patient in a supine position could increase aspiration risk.
(b) placing a restrained patient in a prone position could increase suffocation risk.
(c) a restraint may cause further psychological trauma or traumatic memories.
(d) appropriate alternatives to restraints are to be used only as a last resort.
Answer:
(d) appropriate alternatives to restraints are to be used only as a last resort.

Cognitive Level: Recall/Professional Issues 

Rationale: 
Appropriate alternatives are to be considered first always before the application of any type of restraints. The goal is to use the least restrictive restraint possible and only after unsuccessful use of alternatives. Restraint use should not be part of any routine protocol. There are many risks associated with physically restraining an individual, including risk of aspiration/ suffocation and increased psychological trauma and traumatic memories. Another issue with long-term restraint use is the development of deep vein thrombosis/pulmonary embolus.

Question 7.
A dangerous side effect of Monoamine Oxidase Inhibitor (MAOI) antidepressant overdose is:
(a) hypotension.
(b) hypertension.
(c) sedation.
(d) severe agitation.
Answer:
(b) hypertension.

Nursing Process: Assessment/Psychosocial 

Rationale: 
Severe hypertension can result from monoamine oxidase inhibitors (MAOIs) overdoses, which blocks the metabolism of norepinephrine. Hypotension, sedation, and severe agitation are not associated with MAOI overdose.

Question 8.
The emergency nurse identifies a condition that precipitates sudden cardiac death from blunt trauma to the left anterior chest wall that occurs predominantly in young, healthy, male athletes as:
(a) long QT syndrome.
(b) commotio cordis.
(c) point of maximal impulse.
(d) Kawasaki disease.
Answer:
(b) commotio cordis.

Nursing Process: Analysis/Cardiovascular 

Rationale: 
Commotio cordis causes sudden cardiac death from blunt trauma to the left anterior chest wall, usually from a thrown or batted ball and occurs predominantly in young, male athletes. The cause of death is ventricular fibrillation due to the blow to the chest occurring during a critical point in the cardiac cycle. The long QT syndrome (LQTS) is a disorder of myocardial repolarization characterized by a prolonged QT interval on the electrocardiogram and results from many things including medications, electrolyte disorders, and congenital defects. The point of maximal impulse (PMI) is located in the fifth intercostal space at the midclavicular line. PMI is where the cardiac impulse can be best palpated. The PMI may be displaced with increased right ventricular pressure (large right pleural effusion, right tension pneumothorax) and volume overload (heart failure). Kawasaki disease affects children younger than 5 years with vasculitis that affects medium and small arteries, notably the coronary arteries. It is self-limiting and resolves within 1 to 2 months, although the mortality rate is 1 % to 2%.

Question 9.
Which of the following is NOT a cause of noncardiac pulmonary edema?
(a) Trauma
(b) Aspiration
(c) High altitude 
(d) Pneumothorax
Answer:
(d) Pneumothorax

Nursing Process: Analysis/Respiratory 

Rationale: 
A pneumothorax would not cause fluid accumulation in the pleural space. Trauma may cause rib fractures or thoracic compression, which can rupture alveoli. Aspiration may contribute to a collection of nonendogenous fluids in the alveoli. Sudden movement to a higher altitude may lead to high-altitude pulmonary edema (HAPE).

Question 10.
Which of the following is the initial treatment for a patient with a tracheobronchial injury?
(a) Suctioning to maintain airway patency 
(b) Preparing for chest tube insertion 
(c) Intubating and providing mechanical ventilation 
(d) Preparing for surgical intervention
Answer:
(a) Suctioning to maintain airway patency 

Nursing Process: Intervention/Respiratory 

Rationale: 
The priority intervention is to maintain airway patency, which is accomplished by immediate suctioning. Chest tube insertion and surgical intervention will be necessary after the patient is stabilized. If the patient is intubated, the end of the endotracheal tube must be positioned distal to the injury. It is also advisable to monitor for possible pneumothorax.

Question 11.
Immediate postcardiac arrest care in comatose patients after return of spontaneous circulation (ROSC) includes which of the following?
(a) Maintaining a ventilatory PETC02 between 55 and 60 mm Hg
(b) Maintaining a minimum systolic blood pressure of 80 mm Hg
(c) Maintaining a target temperature of 32° C to 36° C (89.6° F to 96.8° F)
(d) Maintaining arterial oxygen saturation of 90% or greater
Answer:
(c) Maintaining a target temperature of 32° C to 36° C (89.6° F to 96.8° F)

Nursing Process: Intervention/Cardiovascular 

Rationale: 
Maintaining a constant target temperature between 32° C to 36° C (89.6° F to 96.8° F) for 24 hours has been demonstrated to improve neurologic recovery. Ventilation should be titrated to a PETC02 of 35 to 45 mm Hg or a PaC02 of 40 to 45 mm Hg. Hypotension (blood pressure of 90 mm Hg or less) should be treated with fluid bolus or vasopressor infusion. Oxygen delivery should be titrated to the lowest” Fi02 required to achieve an arterial oxygen saturation of 94% to 99% to avoid potential oxygen toxicity.

Question 12.
Which of the following is a true statement regarding a bowel obstruction?
(a) Hyperactive bowel sounds can be heard in a bowel obstruction in certain situations.
(b) Large bowel obstructions usually present with a moderate amount of abdominal swelling.
(c) All bowel obstructions will have a fecal smell to the emesis.
(d) A small bowel obstruction usually has a lesser amount of vomiting.
Answer:
(a) Hyperactive bowel sounds can be heard in a bowel obstruction in certain situations.

Nursing Process: Assessment/Gastrointestinal 

Rationale: 
Bowel obstructions that are in the early stages or are partial obstructions can have hyperactive bowel sounds. These sounds are usually high-pitched. In the later stages and if there is a complete obstruction, the bowel sounds will be absent. In the early phases, the bowel is attempting to overcome the obstruction. A large bowel obstruction will present with a great deal of abdominal swelling, whereas a small bowel obstruction will carry a smaller amount of swelling. Fecal odor to the emesis is a good clue for a bowel obstruction, but it is not always present. Small bowel obstructions usually have a much greater amount of vomiting. 

Question 13.
Which of the following test results provides information that is important immediately following a sexual assault?
(a) Negative serologic test for syphilis 
(b) Normal complete blood count 
(c) Rhogam test for blood type 
(d) Negative pregnancy test
Answer:
(d) Negative pregnancy test

Nursing Process: Analysis/GU/GYN/OB 

Rationale: 
It is important to know if the patient was pregnant when the attack occurred. If she is not pregnant, the appropriate “morning after” medication (ethinyl estradiol and norgestrel) can be given within 72 hours. If the patient chooses to use plan B (morning-after pill), they will need a prescription for an antiemetic as the medication can cause nausea. Other treatments for the patient would include prophylactic antibiotic therapy. Cultures and tests for syphilis will not be resulted for several days. A complete blood count does not provide vital information unless the patient is injured and hypovolemia is suspected. Rhogam will provide information regarding the Rh of the mother. This test is not indicated in this situation.

Question 14.
The classic presentation of thyroid storm includes all of the following EXCEPT:
(a) fever.
(b) tachycardia.
(c) hot, dry skin.
(d) mentation changes.
Answer:
(c) hot, dry skin.

Nursing Process: Assessment/Medical 

Rationale: 
Patients in thyroid storm are heat-intolerant and sweat excessively, which along with vomiting and fever can exacerbate volume loss leading to hypovolemic shock. Patients in thyroid storm typically have a core body temperature of 101.3° F (38.5° C) due to the body’s increased metabolic rate. Hyperpyrexia (core temperature more than 104° F [40° C]) can occur. Mental status changes, seizures, and coma are commonly seen in this condition. Tachycardia is a classic sign of thyroid storm.

Question 15.
When discharging a patient with sickle cell disease, which of the following statements indicates the patient understands how to avoid precipitating a sickle cell crisis? 
(a) “I will self-manage flu-like symptoms for 48 hours before calling my physician.”
(b) “I can continue to participate in cold weather sporting events.”
(c) “When I am angry, I will keep my feelings to myself. ”
(d) “I will drink at least 64 oz of water every day.”
Answer:
(d) “I will drink at least 64 oz of water every day.”

Nursing Process: Evaluation/Medical 

Rationale: 
Dehydration can precipitate a vaso-occlusive crisis in the capillary circulation. Microvascular occlusion leads to tissue ischemia and severe pain. Patients should ensure they have an adequate intake of fluids every day. Infection is a precipitant of sickle cell crisis and patients should seek immediate medical attention at the first signs of malaise. Exposure to cold temperatures results in vasoconstriction of blood vessels in the skin, hands, feet, nose, and ears. This response is greatly exaggerated in the presence of sickle cell disease. Stressful events trigger the release of vasoactive hormones, which narrow blood vessels. This can lead to a vaso-occlusive crisis. Patients with sickle cell disease need strong coping mechanisms and communication skills to address stress.

Question 16.
Common physical manifestations of eating disorders include all of the following EXCEPT:
(a) dehydration/nutritional imbalances.
(b) cardiac dysrhythmias/electrolyte imbalances.
(c) acute renal or hepatic failure.
(d) progressive vision loss/diplopia.
Answer:
(d) progressive vision loss/diplopia.

Nursing Process: Assessment/Psychosocial 

Rationale: 
Dehydration and nutritional abnormalities are present in 47% of admissions, followed by electrolyte imbalances for 34%, cardiac dysrhythmias in 24%, and 4% presenting with renal or hepatic failure. Visual impairment is not a complication.

Question 17.
Following a fall down a flight of stairs, a patient in her 38th week of pregnancy is brought to the emergency department. Unless contraindicated, she should be placed in which position during assessment?
(a) Trendelenburg 
(b) Supine
(c) Left lateral recumbent 
(d) Knee-chest
Answer:
(c) Left lateral recumbent 

Nursing Process: Intervention/GU/GYN/OB 

Rationale: 
The left lateral recumbent position avoids compression of the inferior vena cava; compressing the vessel may result in decreased uterine blood flow, fetal hypoxia, and maternal hypotension. Trendelenburg or a supine position would compress this vessel. If a pregnant patient must lie flat on a backboard for spinal evaluation, a wedge may be placed under the backboard to tilt it, or manual manipulation of the uterus may also be done by a provider. The knee-chest position is used to avoid compressing the umbilical cord when it is prolapsed.

Question 18.
The dementia patient is most likely at .risk of receiving suboptimal emergency care for an acute hip fracture because:
(a) their vascular sufficiency may be compromised and impede healing.
(b) their ability to interpret and communicate pain may be compromised.
(c) they are not competent to consent to a surgical treatment.
(d) it is impossible to keep them in the bed for a thorough evaluation.
Answer:
(b) their ability to interpret and communicate pain may be compromised.

Nursing Process: Analysis/Psychosocial 

Rationale: 
The dementia patient may have impaired ability to assess their own pain and communicate their symptoms. It is incumbent upon the nurse to dedicate adequate attention to objective signs of discomfort such as body posture and vital sign changes. Chronic vascular pathology will not impact emergency care, but attentive monitoring of distal circulation may be a heightened concern due to communication challenges with the patient. If the patient is incompetent to consent to treatment themselves, a surrogate decision maker is indicated. Sedation and/or a bedside sitter may be necessary to ensure patient safety and adequate pain control will facilitate safe care.

Question 19.
Which of the following would be a concern for a patient involved in a major motor vehicle crash who presents with right upper quadrant pain and has a past history of hepatitis C, COPD, and hypertension?
(a) Respiratory distress 
(b) Uncontrolled bleeding 
(c) Hypertensive crisis 
(d) Pneumonia
Answer:
(b) Uncontrolled bleeding 

Nursing Process: Analysis/Gastrointestinal 

Rationale: 
The liver is the major organ involved in hepatitis C and in a motor vehicle crash the emergency nurse should be concerned about the patient’s ability to clot. The liver is extremely involved in the clotting process as most of the necessary clotting factors are produced here. In these traumatic situations, the clotting cascade may not work appropriately. The liver is located in the right upper quadrant and the liver also receives a large amount of cardiac output and has the potential to bleed copiously if damaged. Respiratory distress would be a concern, but the lack of ability to clot would take precedence. There were no symptoms of respiratory distress noted in the stem of the question. Hypertensive crisis is not a concern in this scenario. The emergency nurse should be most concerned about hypotension with the strong possibility of hypovolemic shock being present. Pneumonia may occur later but would not be a primary concern in this case.    

Question 20.
Which of the following is another sign of burn inhalation injury besides hoarseness?
(a) Rapid easing of the work of respiration 
(b) Carbonaceous or black-tinged sputum 
(c) Persistent wet and productive cough 
(d) Moist mucous membranes
Answer:
(b) Carbonaceous or black-tinged sputum 

Nursing Process: Assessment/Respiratory 

Rationale: 
Black-tinged (carbonaceous) sputum from smoke generated in the fire is a hallmark sign of inhalation injury. Respirations may become increasingly difficult as the injury matures. The mucous membranes of the burn-injured patient are commonly dry. The patient may have rales and rhonchi on auscultation, but the cough is dry and generally nonproductive.

Question 21.
Cardiac output (CO) is a product of which of the following formulas?
(a) Preload x Afterload 
(b) Zone 1 x Zone 2 
(c) Heart rate x Stroke volume 
(d) (Age in years)/4 + 4
Answer:
(c) Heart rate x Stroke volume 

Nursing Process: Analysis/Cardiovascular 

Rationale: 
Cardiac output (CO) is defined as a product of heart rate (HR) and stroke volume (SV) (CO = HR x SV). Preload is the passive stretching force of the ventricles during diastole; afterload is the resistance of the system that the ventricles must overcome in order to eject blood. Zone 1 and Zone 2 are anatomic landmarks of the neck and serve to identify structures in each zone. (Age in years)/4 + 4 is the formula to estimate pediatric endotracheal tube size.

Question 22.
Proton pump inhibitors are used in patients with gastroesophageal reflux disease (GERD) because of which of the following actions?
(a) Increases lower esophageal sphincter pressure 
(b) Reduces secretions in the stomach 
(c) Lowers acid present in the stomach 
(d) Decreases the production of acid
Answer:
(d) Decreases the production of acid

Nursing Process: Analysis/Gastrointestinal 

Rationale: 
Proton pump inhibitors such as omeprazole (Prilosec) and pantoprazole (Prevacid) decrease the production of acid in the stomach and cause a reduction of irritation of the lining of the stomach. These also help kill the organism Helicobacter pylori when used in combination with antibiotics. Medications such as metoclopramide (Reglan) help to increase lower esophageal sphincter pressure. Ranitidine (Zantac) and famotidine (Pepcid) reduce secretions, and maalox and mylanta lower the acid content that is present in the stomach.

Question 23.
It is the plaintiff's responsibility to prove certain elements in a negligence lawsuit. Which of the following is NOT one of these elements?
(a) A duty was owed to the patient.
(b) The defendant breached the duty.
(c) This breach of duty was the cause of the plaintiff’s injury.
(d) The plaintiff was at risk for an injury because of the breach of duty.
Answer:
(d) The plaintiff was at risk for an injury because of the breach of duty.

Cognitive Level: Application/Professional Issues 

Rationale: 
The plaintiff must prove that the injuries sustained were real or actual. The plaintiff must prove that the defendant owed him a specific duty, that the defendant breached this duty, that the plaintiff was harmed physically, mentally, emotionally, or financially, and that the defendant’s breach of duty caused this harm. The plaintiff must also prove foreseeability and damages.

Question 24.
Which of the following would indicate an improvement in a patient with a diagnosis of serotonin syndrome?
(a) Increased heart rate 
(b) Normothermia 
(c) Mydriasis 
(d) Dry mucous membranes
Answer:
(b) Normothermia 

Nursing Process: Evaluation/Psychosocial 

Rationale: 
Hyperthermia is a trademark symptom of serotonin syndrome, therefore, normothermia would indicate an improvement in this patient. Other manifestations include tachycardia, dilated pupils (mydriasis), and dry mucous membranes as well as agitation, hyperreflexia, diaphoresis, and flushed skin.

Question 25.
Treatment for norovirus includes all of the following EXCEPT:
(a) antibiotic therapy.
(b) rehydration.
(c) bed rest.
(d) strict handwashing.
Answer:
(a) antibiotic therapy.

Nursing Process: Intervention/Gastrointestinal 

Rationale: 
Viruses are not treated with antibiotics. Treatment for norovirus is supportive care, which includes rehydration through intravenous fluids if necessary, rest which usually includes bed rest for a day or two, and strict handwashing to prevent further contamination.

Question 26.
Which of the following statements made by a patient being discharged with a diagnosis of trichomonas and placed on a regimen of metronidazole (Flagyl) indicates that instructions were understood?
(a) “I’m very glad that I don’t have to tell anyone about this.”
(b) “I’m so excited that I just found out that I am pregnant.”
(c) “I should not drink alcohol while I am taking this medication.”
(d) “The doctor said this would not impact my Coumadin medication.”
Answer:
(c) “I should not drink alcohol while I am taking this medication.”

Nursing Process: Evaluation/GU/GYN/OB 

Rationale: 
Alcohol should not be used while the patient is taking metronidazole (Flagyl). It will cause extreme vomiting, headaches, and flushing. Patients who are diagnosed with trichomonas must share this information with their sexual partners and they should be treated as well. Patients who are in the first trimester of pregnancy should not take metronidazole (Flagyl). Metronidazole (Flagyl) can potentiate the effects of warfarin (Coumadin), resulting in a prolonged prothrombin time.

Question 27.
A patient is complaining of chest pain unrelieved with rest. The electrocardiogram shows T-wave inversion and there is no elevation in troponin. The emergency nurse suspects which of the following disease entities?
(a) Stable angina
(b) Unstable angina
(c) Non-ST elevation myocardial infarction (Non-STEMI)
(d) ST-elevation myocardial infarction (STEMI)
Answer:
(b) Unstable angina

Nursing Process: Assessment/Cardiovascular 

Rationale: 
Unstable angina is characterized by the classic signs of continued chest pain despite rest or nitroglycerin and no elevation of troponin. Stable anginal pain goes away with rest. Non-STEMI is defined as depression or T-wave inversion with elevation of cardiac biomarkers. STEM1 (ST-elevation myocardial infarction) definition requires ST elevation in two or more contiguous leads or new left bundle branch block and troponin elevation beyond the 99th percentile of the upper reference limit.

Question 28.
A patient has a history of heart failure and has been diagnosed with pneumonia. Audible, adventitious lung sounds are present. Which of the following sounds would the nurse NOT expect to hear?
(a) Stridor 
(b) Crackles 
(c) Wheezing 
(d) Rhonchi 
Answer:
(a) Stridor 

Nursing Process: Assessment/Respiratory

Rationale: 
Stridor is located in the upper airway and is a result of partial obstruction of the larynx or trachea. Crackles, wheezing, and rhonchi are all possible with a patient experiencing an exacerbation of heart failure or pneumonia.

Question 29.    
Atypical antipsychotic drugs affect the dopamine and serotonin receptors and have lower compared with typical antipsychotic medications.
(a) daily compliance
(b) extrapyramidal syndromes 
(c) financial burden 
(d) therapeutic benefits
Answer:
(b) extrapyramidal syndromes 

Nursing Process: Evaluation/Psychosocial 

Rationale: 
Extrapyramidal side effects are diminished compared with typical antipsychotics and therefore have increased compliance. The atypicals also demonstrate benefits in reducing symptoms associated with psychosis such as hostility, violence, and suicidal behavior. This class of drug is relatively more expensive when compared with typical antipsychotic medications.

Question 30.
When utilizing the pH method of confirmation of gastric tube placement, which of the following numbers would indicate that the tube is in the stomach?
(a) 4.0 
(b) 8.5 
(c) 10.0 
(d) 14.5
Answer:
(a) 4.0 

Nursing Process: Evaluation/Gastrointestinal 

Rationale: 
The pH of gastric contents should be acidic, which would correlate with an acid pH of 1 to 5.5. Any number above 5.5 must have a radiograph to confirm placement. (Radiograph is the preferred method.)

Question 31.
Which of the following changes on the electrocardiogram would the emergency nurse recognize as being indicative of an acute myocardial infarction?
(a) ST-segment depression.
(b) Dynamic T-wave inversion.
(c) Nondiagnostic changes in ST segment.
(d) ST-segment elevation.
Answer:
(d) ST-segment elevation.

Nursing Process: Assessment/Cardiovascular 

Rationale: 
ST-segment elevation is strongly suspicious for myocardial injury for ST-elevation myocardial infarction (STEMI). ST-segment depression and dynamic T-wave inversion are suspicious for ischemia. Nondiag-nostic changes in ST segment or T wave are low/intermediate risk for acute coronary syndrome.

Question 32.
The provider has diagnosed a patient with a hydatidiform mole. The emergency nurse will expect the human gonadotropin level to be:
(a) zero.
(b) very low.
(c) very high.
(d) normal for gestational age.
Answer:
(c) very high.

Nursing Process: Assessment/GU/GYN/OB 

Rationale: 
A hydatidiform mole or gestational trophoblastic tumor demonstrates an extremely elevated human chorionic gonadotropin level. Other signs include a snowstorm pattern on ultrasound, early preeclampsia, absence of fetal heart tones, bleeding or spotting, and enlarged uterus.

Question 33.
Which of the following is a true statement regarding breach of duty?
(a) Willful violation of an oath or code of ethics regarding patient care
(b) Failure to meet accepted standards in providing care for a patient
(c) Threatening a patient with withholding pain medication
(d) Confining a patient to a psychiatric unit without a physician’s order
Answer:
(b) Failure to meet accepted standards in providing care for a patient

Cognitive Level: Application/Professional Issues 

Rationale: 
If a patient sues a nurse for negligence, the patient must prove that the nurse owed him a specific duty and that the nurse breached this duty. A breach of duty in this case means that the nurse did not provide care within the accepted standard. A breach is not always willful, as implied in option A. Threatening a patient is assault, more accurately described as a direct invasion of a patient’s rights rather than a breach of duty. Confining a patient to a psychiatric unit without a physician’s order is false imprisonment, which is another example of direct invasion of a patient’s rights.

Question 34.
A vesicular rash and fever are indicative of which of the following infectious diseases?
(a) Kawasaki disease 
(b) Varicella zoster 
(c) Lyme disease 
(d) Meningococcemia
Answer:
(b) Varicella zoster 

Nursing Process: Assessment/Communicable Diseases 

Rationale: 
Varicella zoster lesions are fluid-filled vesicles, most commonly affecting the thoracic derma-tome. The patient may have flu-like symptoms with or without fever. A petechial rash of small, pinpoint lesions progressing rapidly to purpura is the characteristic manifestation of meningococcemia. Petechial and purpuric lesions develop from bleeding under the skin and do not blanch on applying pressure. Fever has a sudden onset and rises quickly. Kawasaki disease is a rare childhood illness, which presents with a fever and rash of poorly defined spots of various sizes, often bright red that blanch when pressure is applied. The rash of Lyme disease begins at the site of a tick bite after a delay of 3 to 30 days (average is about 7 days). It expands gradually over a period of days reaching up to 12" or more (30 cm) 'across. As it enlarges, the center clears, resulting in a target or “bull’s-eye” appearance.

Question 35.
In certain cases, which of the following medications may be used to medically manage an ectopic pregnancy instead of surgery?
(a) Doxycycline (Vibramycin)
(b) Ceftriaxone (Rocephin)
(c) Methotrexate (Trexall)
(d) Metronidazole (Flagyl)
Answer:
(c) Methotrexate (Trexall)

Nursing Process: Intervention/GU/GYN/OB 

Rationale: 
Methotrexate (Ttexall), a cytotoxic medication, is a folic acid antagonist and inhibits further duplication of fetal cells. Doxycycline (Vibramycin), ceftriaxone (Rocephin), and metronidazole (Flagyl) are antibiotics and not used for this condition but are used in the treatment of pelvic inflammatory disease (PID).

Question 36.
Which of the following classes of medications would most likely NOT be prescribed in an emergency care environment due to their slow onset of effectiveness?
(a) Typical antipsychotic 
(b) Atypical antipsychotic 
(c) Benzodiazepine
(d) Selective serotonin reuptake inhibitor (SSRI)
Answer:
(d) Selective serotonin reuptake inhibitor (SSRI)

Nursing Process: Intervention/Psychosocial 

Rationale: 
While frequently effective after days or weeks of use, the SSRI (Selective Serotonin Reuptake Inhibitor) medications are not an acutely beneficial emergency department intervention. All the other drugs have an onset that may be beneficial during a typical emergency department stay.

Question 37.
A patient in the emergency department is being evaluated for acute kidney injury (AKI) and appears very ill. A urinalysis and CBC have been ordered. Which of the following additional tests would be most beneficial to determine the severity and acuity of renal failure and would require immediate life-saving interventions?
(a) Intravenous pyelogram (IVP)
(b) Blood urea nitrogen (BUN)
(c) Renal arteriogram 
(d) Serum potassium
Answer:
(d) Serum potassium

Nursing Process: Assessment/Medical 

Rationale: 
The most common electrolyte imbalances seen in acute renal failure are hyperkalemia, hyponatremia, hypocalcemia, and hyperphosphatemia. Hyperkalemia is a life-threatening electrolyte disturbance requiring immediate treatment. An intravenous pyelogram visualizes abnormalities of the urinary system, including the kidneys, ureters, and bladder, and evaluates the flow of urine through the renal system. Renal angiography can be helpful in establishing the etiology of renal vascular diseases, including renal artery stenosis, but does not assist in determining the severity or acuity. An elevated blood urea nitrogen (BUN) is a hallmark of acute kidney injury but is not considered a life-threatening condition.

Question 38.
Which of the following is the expected primary treatment outcome of postrenal acute kidney injury?
(a) Increase outflow of urine from the kidney
(b) Increase renal artery perfusion 
(c) Increase systemic blood pressure
(d) Decrease systemic blood pressure
Answer:
(a) Increase outflow of urine from the kidney

Nursing Process: Evaluation/Medical

Rationale: 
Postrenal acute kidney injury is the result of an obstruction of the urinary collection system from the calices of the kidney to the urethral meatus. Relief of the obstruction and allowing urine to flow out of the kidney is the intention of treatment interventions. Increasing renal artery perfusion and increasing or decreasing systemic blood pressure are interventions which influence prerenal acute kidney injury.

Question 39.
Which of the following is a true statement regarding caring for individuals who are diagnosed with Clostridium difficile infection?
(a) The use of alcohol-based hand cleansers is extremely useful and recommended.
(b) Patients should remain in isolation for at least 48 hours after the last diarrhea stool.
(c) Gowns and masks are not necessary to wear when caring for these patients.
(d) Private rooms are not necessary when these patients are admitted for inpatient care.
Answer:
(b) Patients should remain in isolation for at least 48 hours after the last diarrhea stool.

Nursing Process: Intervention/Communicable 

Rationale: 
Patients can continue to shed the Clostridium difficile spores for a number of days after the last diarrheal stool. Therefore, it would be advantageous for them to remain in isolation even after their diarrhea has stopped. Clostridium difficile is not killed by alcohol. Alcohol-based hand cleansers are not adequate for the health care providers to use during the care of these patients. Soap and water are the best hand cleanser agents to use. Gloves are actually best as even handwashing cannot always adequately prevent the spread of this organism. Gowns should be worn when caring for these individuals. Private rooms are necessary or at least room the patient with another patient who is diagnosed with C. difficile. This is known as “cohorting.”

Question 40.
A patient is brought to the emergency department with mild respiratory distress. His oxygen saturation is 95 % on 3 liters of oxygen via nasal cannula, respiratory rate is 28 breaths/minute, and temperature is 101 ° F (38.3° C). He has decreased breath sounds over the base of the right lung and complains of a nonproductive cough. He has a history of tuberculosis. Based on these assessment findings, which of the following should the nurse suspect?
(a) Empyema
(b) Transudative effusion
(c) Exudative effusion 
(d) Pulmonary embolus 
Answer:
(a) Empyema

Nursing Process: Analysis/Respiratory 

Rationale: 
An empyema contains pus and can be caused by tuberculosis. Transudative effusion is common with heart failure, renal and liver disease, and exudative effusions are secondary to pulmonary malignancies, pulmonary embolus, and GI disease. Patients with pulmonary embolus often present with hypoxia and tachycardia and are afebrile.

Question 41.
The patient with chronic bronchitis requires careful monitoring when receiving which of the following treatments?
(a) Oxygen therapy 
(b) Increased fluids 
(c) Humidified air 
(d) Postural drainage
Answer:
(a) Oxygen therapy 

Nursing Process: Evaluation/Respiratory 

Rationale: 
The patient with chronic bronchitis should be monitored closely when given low-flow oxygen to decrease the chances of depressing the respiratory drive because hypoxia becomes the stimulus to breathe for these patients. Increasing fluids to liquefy secretions, humidifying the air, and performing postural drainage are also important therapies for a patient with chronic bronchitis.

Question 42.
A radiograph demonstrates a “buckle” fracture of the arm. The emergency nurse knows this fracture is also known as which of the following types of fracture?
(a) Torus 
(b) Greenstick 
(c) Compression 
(d) Comminuted
Answer:
(a) Torus 

Nursing Process: Analysis/Orthopedic 

Rationale: 
A “buckle” fracture is also known as a torus fracture. This is demonstrated by no disruption of the cortex. In a “greenstick” fracture, the cortex does show disruption on the involved side. Both torus and green-stick fractures are breaks that involve one side of the bone, but there is a difference. In compression fractures, the bone collapses onto itself, and in comminuted fractures, the bone is splintered or fragmented with two or more fragments of bone involved. This can commonly occur with gunshot wounds, but can also be direct blunt trauma.

Question 43.
On the basis of the relationship and time frame commonly available for patient education in the emergency department, which of the following kinds of learning goals are best established with a patient in this setting?
(a) Long term 
(b) Short term 
(c) Middle range 
(d) Tertiary range
Answer:
(a) Torus 

Cognitive Level: Application/Professional Issues 

Rationale: 
Short-term goals are the only ones that the emergency nurse will be able to provide in this setting. There is no long-term, ongoing relationship in the ED setting (typically!). Middle-range goals and tertiary-range goals do not exist.

Question 44.
Cardiogenic shock is the result of myocardial pump failure, decreased cardiac output (CO), and inadequate tissue perfusion most commonly caused by myocardial infarction or ischemia. Signs and symptoms would include which of the following?
(a) Tachypnea, crackles, hypotension, pale, and clammy skin
(b) Dyspnea, stridor, wheezing, bronchospasm, and erythema
(c) Bradycardia, hypotension, and warm, dry skin 
(d) Tachycardia, altered level of consciousness, and uncontrolled external bleeding
Answer:
(a) Tachypnea, crackles, hypotension, pale, and clammy skin

Nursing Process: Analysis/Cardiovascular 

Rationale: 
Most patients who present with cardiogenic shock do so in conjunction with a myocardial infarction. Clinical manifestations of cardiogenic shock reflect heart failure and inadequate tissue perfusion, that is, tachypnea, crackles, hypotension, and pale, clammy skin. Anaphylactic shock from allergic reaction presents with dyspnea, stridor, wheezing, bronchospasm, and erythema. Neurogenic shock includes signs/symptoms of bradycardia, hypotension, and warm, dry skin. Tachycardia, altered level of consciousness, and uncontrolled external bleeding are signs of hypovolemic shock.

Question 45.
Which of the following would be the best manner to check for proper gastric tube placement?
(a) Listen for instilled air over the epigastrium 
(b) Radiograph or computed tomography (CT) to confirm placement 
(c) pH testing of gastric aspirate 
(d) Use of carbon dioxide detector
Answer:
(b) Radiograph or computed tomography (CT) to confirm placement 

Nursing Process: Evaluation/Gastrointestinal 

Rationale: 
The method now recommended to achieve the highest level of certainty of proper placement of a nasogastric tube is to have radiograph or computed tomography (CT) evidence. The next recommended method is to utilize pH testing of the gastric aspirate. The use of a carbon dioxide detector to determine it is not in the lungs is the third highest recommendation, although it is considered to be weak. The common practice of listening over the stomach area for the sound of instilled air is not recommended anymore. This is an unreliable method.

Question 46.
Which of the following indicates the possibility of a urethral injury during a rectal examination of a trauma patient?
(a) Low-riding prostate 
(b) High-riding prostate 
(c) Absent sphincter tone 
(d) Positive hemoccult test
Answer:
(b) High-riding prostate 

Nursing Process: Assessment/GU/GYN/OB 

Rationale: 
When the urethra is torn, a hematoma or collection of blood separates the two sections of the urethra. This may feel like a boggy mass on rectal examination and the prostate becomes “high riding.” A palpable prostate gland usually indicates an intact urethra. Absent sphincter tone would refer to a spinal cord injury. The presence of blood in the rectum would probably correlate with a GI bleed or colon injury.

Question 47.
Which of the following is the normal range for arterial blood pH?
(a) 7.38 to 7.46 
(b) 7.40 to 7.52 
(c) 7.35 to 7.45 
(d) 7.28 to 7.38
Answer:
(c) 7.35 to 7.45 

Nursing Process: Assessment/Medical 

Rationale: 
Tight regulation of [H + ] is crucial for normal cellular activities. The body requires a pH of 7.35 to 7.45 to maintain homeostasis. pH values below 7.35 are reflective of acidosis and values in excess of 7.45 represent alkalosis.

Question 48.
Which of the following is the main route of transmission for infectious mononucleosis?
(a) Blood 
(b) Skin lesions 
(c) Stool 
(d) Saliva
Answer:
(d) Saliva

Nursing Process: Analysis/Communicable Diseases 

Rationale: 
The main causal agent of infectious mononucleosis is the Epstein-Barr virus. The usual route of transmission is oropharyngeal through saliva. Hence, its moniker as the “kissing disease.” The virus is not found in blood or stool. It is not passed by contact with skin lesions. Classic symptoms of mononucleosis include a flu-like prodromal period lasting 3 to 5 days followed by fever, pharyngitis, and lymphadenopathy. No rash is associated with mononucleosis.

Question 49.
An unrestrained driver arrives in the emergency department after a roll-over crash at 80 miles/hour. Which of the following are the most common causes of pulseless electrical activity (PEA) rhythm for this patient?
(a) Hypovolemia and hypoxia
(b) Thrombosis and toxins 
(c) Hydrogen ion acidosis and hypothermia 
(d) Hypoglycemia and syncope
Answer:
(a) Hypovolemia and hypoxia

Nursing Process: Analysis/Cardiovascular 

Rationale: 
Hypovolemia and hypoxia are the two most common underlying and potentially reversible causes of pulseless electrical activity in the trauma patient. Uncontrolled bleeding and resultant hypovolemia may occur after a crash of an unrestrained driver at high speeds. Although thrombosis, toxins, acidosis, and hypothermia are causes of pulseless electrical activity according to the American Heart Association, they are not necessarily implicated in a car crash at high speeds. Hypoglycemia and syncope are not common causes of pulseless electrical activity according to the American Heart Association.

Question 50.
Which of the following is the most serious injury associated with a fracture of the first or second rib?
(a) Cervical spine injury 
(b) Aortic rupture 
(c) Tracheal tear 
(d) Clavicular fracture
Answer:
(b) Aortic rupture 

Nursing Process: Analysis/Respiratory 

Rationale: 
Although a cervical spine injury, tracheal tear, or clavicular fracture can be associated with a fracture of the first or second rib, the most serious injury is aortic rupture, which often results in immediate death from severe hemodynamic compromise. 5uspect an aortic rupture in a trauma patient with motor, sensory, or pulse deficits in the lower extremities. Such deficits usually result from disruption of blood flow to the spinal cord. Other symptoms include unexplained hypotension and chest or back pain. A cervical spine injury can also be serious, especially if it involves a C3, C4, or higher lesion, which can result in respiratory depression. Tracheal tears lead to pneumomediastinum and have the potential for tension pneumothorax if undetected. Clavicular fractures cause great pain; however, they seldom cause more severe consequences.

Question 51.
The emergency nurse realizes that the student nurse understands premature atrial contractions when the student makes which of the following statements?
(a) “Premature atrial complexes may precede supraventricular tachycardia, atrial flutter, or atrial fibrillation.”
(b) “Premature atrial complexes may occur in a saw-toothed pattern and are called flutter waves.”
(c) “Premature atrial complexes are characterized by a chaotic atrial rhythm and an irregular ventricular response. ”
(d) “Premature atrial complexes occur with accessory conduction system pathways that predispose to reentrant rhythms.”
Answer:
(a) “Premature atrial complexes may precede supraventricular tachycardia, atrial flutter, or atrial fibrillation.”

Nursing Process: Evaluation/Cardiovascular 

Rationale: 
Premature atrial complexes may precede supraventricular tachycardia, atrial flutter, or atrial fibrillation. These complexes appear on the electrocardiogram as identical to the patient’s PQRST complexes but are “premature” or early in the pattern. Flutter waves occur in atrial flutter and appear as a sawtooth pattern which can be variable. Atrial fibrillation is characterized by a chaotic atrial rhythm associated with an irregular ventricular response. Supraventricular tachycardia is common in the pediatric population, some of whom are born with accessory conduction system pathways that predispose them to reentrant rhythms.

Question 52.
A patient arrives in the emergency department with complaints of chest pain for the last 30 minutes after mowing the lawn. He also reports nausea, dyspnea, and dizziness. The 12-lead electrocardiogram shows greater than 2 mm ST elevation in leads V1; V2, and V3. This indicates injury to which of the following areas of the heart?
(a) Inferior 
(b) Lateral 
(c) Anterior 
(d) Posterior
Answer:
(c) Anterior 

Nursing Process: Assessment/Cardiovascular 

Rationale: 
ST-segment elevation in leads V1, V2, and V3 are indicative of damage to the anterior aspect of the heart. These leads look directly at the anterior heart wall. Inferior myocardial infarctions are noted with changes in leads II, III, and AVF. The lateral leads are I, AVL, V5, and V6. Posterior Mis are noted as reciprocal changes in the anterior leads—V1 and V2. To see the ST-segment elevation changes in this Ml, posterior leads— V7, V8, and V9—would need to be performed.

Question 53.
An unrestrained patient is brought to the emergency department after a motor vehicle crash. He is alert and oriented with the following vital signs:
Blood pressure—88/40 mm Hg 
Pulse—42 beats/minute 
Respirations—22 breaths/minute 
Pulse oximetry—95 % on room air 
Temperature—99.2° F (37.3° C)

This is most likely due to which of the following types of shock?
(a) Hypovolemic 
(b) Neurogenic 
(c) Anaphylactic 
(d) Septic
Answer:
(b) Neurogenic 

Nursing Process: Assessment/Neurologic/Shock 

Rationale: 
The hallmark of neurogenic shock is bradycardia. This occurs due to the loss of sympathetic responses. The parasympathetic system is in control. The vagal response associated with this system is bradycardia. Hypovolemic, anaphylactic, and septic types of shock all have tachycardia as a predominant symptom.

Question 54.
Which of the following is NOT a common sign or symptom of a pulmonary embolus (PE)?
(a) Acute respiratory distress 
(b) Nonproductive cough 
(c) Bradycardia 
(d) Sudden chest pain
Answer:
(c) Bradycardia 

Nursing Process: Assessment/Respiratory 

Rationale: 
Tachycardia, not bradycardia, is seen with a pulmonary embolus (PE). Acute respiratory distress, nonproductive cough, and chest pain are all signs and symptoms of a PE.

Question 55.
A patient arrives in the emergency department stating that she was sexually assaulted multiple times over the past 12 hours. She is tearful and accompanied by a friend. The emergency nurse knows that which of the following is the most important piece of information from this patient at this time?
(a) She notified the police.
(b) She uses birth control.
(c) She has changed clothing.
(d) She has been sexually assaulted before.
Answer:
(c) She has changed clothing.

Nursing Process: Assessment/GU/GYN/OB 

Rationale: 
Whether the patient has changed her clothes, or even brushed her teeth since the attack, is critical to evidence collection and preservation. It is also helpful if the patient has not showered, urinated, or defecated. Determining if the patient has notified the police is also important, but does not affect the assessment. It is not relevant to know if she has been previously sexually assaulted or if she is using a method of birth control at this time.

Question 56.
Which of the following interventions is NOT considered appropriate for a patient with placenta previa?
(a) Performing a pelvic examination to determine cervical dilatation
(b) Maintaining strict bed rest and observing for further bleeding
(c) Monitoring for signs of shock 
(d) Preparing the patient for ultrasound
Answer:
(a) Performing a pelvic examination to determine cervical dilatation

Nursing Process: Intervention/GU/GYN/OB 

Rationale: 
A pelvic examination should not be performed on a pregnant patient with vaginal bleeding in the third trimester. This can cause further bleeding and damage the placenta. The patient should be placed on bed rest, monitor a pad count, and be admitted if bleeding is heavy and persists. A pelvic ultrasound is useful for detecting placenta previa.

Question 57.
A provider has just asked the patient “How many fingers do you see?” This question is assessing which of the following cranial nerves?
(a) Cranial nerve II (Optic)
(b) Cranial nerve III (Oculomotor)
(c) Cranial nerve IV (Trochlear)
(d) Cranial nerve VI (Abducens)
Answer:
(a) Cranial nerve II (Optic)

Nursing Process: Assessment/Neurologic 

Rationale: 
Cranial nerve II, the Optic nerve, assesses visual acuity, dark versus light, and the counting of fingers. Cranial nerve III, Oculomotor, gives the eye the ability to constrict the pupils, move the eyeball, and open the eyelid. Cranial nerve IV, Trochlear, allows the eye to look downward and outward, and cranial nerve VI, Ab- ducens, assists the eyeball to rotate outward.

Question 58.
A patient is brought to the emergency department by emergency medical services after being crushed while standing between a loading dock and a truck. The emergency nurse can anticipate which of the following injuries?
(a) Humeral head fracture 
(b) Closed pelvic fracture 
(c) Humeral shaft fracture 
(d) Open-book pelvic fracture
Answer:
(d) Open-book pelvic fracture

Nursing Process: Assessment/Orthopedic 

Rationale: 
In this scenario, the anticipated mechanism of injury would be an open-book pelvic fracture because the patient was crushed between two objects in a standing position. Because the patient was standing, it is unlikely his humerus or humeral head would be impacted by the crush. Closed pelvic fractures are generally caused by lateral compression from motor vehicle crashes.

Question 59.
Which of the following are the earliest signs of hypovolemic shock?
(a) Tachycardia, restlessness, and thirst 
(b) Hypoxia, dysrhythmias, and tremors 
(c) Hypotension, flushed extremities, and anxiety 
(d) Oliguria, cyanosis, and confusion
Answer:
(a) Tachycardia, restlessness, and thirst 

Nursing Process: Assessment/Orthopedic Shock 

Rationale: 
Tachycardia, restlessness, and thirst are often seen early in hypovolemic shock. Tachycardia is due to increased epinephrine secretion in response to a decreased preload. Restlessness can occur from the epinephrine secretion as well as hypoxemia. Thirst is due to decreased extracellular fluid in mucous membranes as it is being shunted back to core circulation. This epinephrine secretion is due to the compensatory effects of the “fight-or-flight” response. The other manifestations would occur in later phases.

Question 60.
The peak frequency of onset and diagnosis of schizophrenia is in which of the following age groups?
(a) 5 to 14 years
(b) 15 to 24 years 
(c) 25 to 34 years 
(d) 35 to 44 years
Answer:
(b) 15 to 24 years 

Nursing Process: Analysis/Psychosocial

Rationale:
The highest frequency of onset/diagnosis of schizophrenia is in the age group of 15 to 24 years.

Question 61.
Upon initial interaction with the agitated patient, the most appropriate response would include which of the following?
(a) Medication intervention 
(b) Isolation initiation 
(c) Restraint preparation 
(d) Verbal de-escalation
Answer:
(d) Verbal de-escalation

Nursing Process: Intervention/Psychosocial 

Rationale: 
It is appropriate to initiate interventions with the agitated patient with the least invasive means. It is appropriate to escalate the level of intervention in response to ineffective therapeutic effect through isolation, medication, or as a last resort restraint.

Question 62.
A patient is brought to the emergency department by ambulance with a chief complaint of lethargy. Two days before, the patient was in a high-speed motor vehicle accident and refused care. Since that time, she has complained of headaches and drowsiness. Her friend states that it has now become difficult to wake her up. Assessment reveals a right pupil that is fixed and dilated with papilledema present. The Glasgow Coma Scale score is 8. Which of the following types of injury does this patient exhibit?
(a) Subdural hematoma 
(b) Epidural hematoma 
(c) Diffuse axonal injury 
(d) Post-concussion syndrome
Answer:
(a) Subdural hematoma 

Nursing Process: Analysis/Neurologic 

Rationale: 
A subdural hematoma, occurring between the dura mater and the arachnoid layer of the meninges, is bleeding that causes direct pressure to the surface of the brain. Signs and symptoms appear within 48 hours (acute) and can be delayed as long as several months (chronic). Symptoms of an epidural hematoma include a history of momentary loss of consciousness followed by a lucid period after which the patient’s mental status deteriorates rapidly due to the presence of bleeding from the middle meningeal artery. The clinical manifestations of a diffuse axonal injury are immediate and prolonged coma with decorticate or decerebrate posturing. Manifestations of postconcussion syndrome include headache, dizziness, irritability, poor judgment, and insomnia.

Question 63.
A patient is bought to the emergency department with a past history of hepatitis C, cardiac stents, and hypertension. He is vomiting large amounts of bright red blood and is nauseated. No pain is present. Based on this patient’s presentation and his present symptoms, which of the following medications should the emergency nurse expect to utilize?
(a) Octreotide (Sandostatin)
(b) Nitroprusside (Nipride)
(c) Amiodarone (Cordarone)
(d) Flumazenil (Romazicon)
Answer:
(a) Octreotide (Sandostatin)

Nursing Process: Intervention/Gastrointestinal

Rationale: 
This patient is experiencing symptoms con-sistent with esophageal varices, which also matches his past history of hepatitis C. Cirrhosis is a complicating factor of hepatitis C. The medication used for this is octreotide (Sandostatin). Nitroprusside (Nipride) is an antihypertensive that is used for emergencies in which blood pressures must be dropped. Amiodarone (Corda- rone) is used for dysrhythmias, which would not match with this scenario. Flumazenil (Romazicon) is the antidote for benzodiazepine overdose.

Question 64.
A patient with a past history of intravenous substance abuse presents with confusion, abdominal distension, and bilateral icteric conjunctiva. Lactulose (Cholac) is prescribed for this patient. Which of the following laboratory values would be monitored to determine the effect of the lactulose?
(a) Ammonia 
(b) Magnesium 
(c) Potassium 
(d) Sodium
Answer:
(a) Ammonia 

Nursing Process: Evaluation/Gastrointestinal 

Rationale: 
High ammonia levels are found in patients who are experiencing hepatic encephalopathy and the patients are treated with lactulose (Cholac). This patient, with a prior history of intravenous substance abuse, is presenting with manifestations of this disease process. Other electrolytes, including potassium, sodium, and magnesium, are noted to be deficient in liver failure; however, lactulose (Cholac) is not utilized to treat these deficiencies.

Question 65.
A patient arrives at the emergency department with signs and symptoms consistent with a non-ST elevation myocardial infarction (NSTEMI). His vital signs are as follows: blood pressure, 100/68 mm Hg; pulse, 46 beats/minute; and respirations, 24 breaths/minute. The physician decides to transfer him to another facility by air. After stabilizing the patient with oxygen, an arterial line, intravenous line placement, and appropriate medication therapy, which of the following should be considered before transport via aircraft?
(a) Nothing; the patient is ready to be transported.
(b) The effect of air transport on the arterial line pressure bag
(c) The ability of the patient’s family to accompany the patient
(d) Ensuring that vital signs are documented just before departure
Answer:
(b) The effect of air transport on the arterial line pressure bag

Cognitive Level: Analysis/Professional Issues 

Rationale: 
Altitude changes will cause changes in air pressure, causing a hypobaric environment, whereby the pressure decreases as altitude increases. There will be enough of a pressure change to cause an arterial line pressure bag to lose some pressure, which may result in an inaccurate arterial blood pressure reading. The patient is not ready to be transported as of yet. The arterial line must be considered and any other altitudinal changes that might impact the patient. Family cannot accompany the patient on board the aircraft. Documenting vital signs is important but only after the arterial line pressure bag is stabilized.

Question 66.
Tricyclic antidepressant overdoses have three main toxic features. These features are cardiotoxicity, adrenergic blocking, and:
(a) anticoagulation.
(b) anticholinergic effects.
(c) sympathomimetic effects.
(d) central nervous system excitation.
Answer:
(b) anticholinergic effects.

Nursing Process: Assessment/Toxicology 

Rationale: 
The three effects associated with tricyclic antidepressant overdoses are cardiotoxicity (prolonged PR interval, widened QRS, prolonged QT interval, heart blocks, and asystole), adrenergic blocking leading to hypotension, and anticholinergic effects (dry skin and mouth with a depressed level of consciousness). There are no anticoagulation or sympathomimetic effects and the central nervous system is depressed rather than excited.

Question 67.
A patient is brought to the emergency department with burns sustained when he fell backward into a fire pit. The palms of his hands have linear charred markings and are leathery to palpation. His lower back and upper posterior thighs have reddened, blistered areas and his nylon shorts are melted into his skin. When the shorts are pulled away, the underlying skin is patchy white or charred-looking. The patient complains of pain to his back and thighs, but not his buttocks or hands. Which of the following would be the suspected depth of burn associated with his hands and buttocks?
(a) Superficial epidermal—first degree 
(b) Superficial partial thickness—second degree 
(c) Deep partial thickness—second degree 
(d) Full-thickness—third degree
Answer:
(d) Full-thickness—third degree

Nursing Process: Assessment/Environmental 

Rationale: 
The patient’s hands and buttocks are full-thickness often called third-degree burns because they are charred or patchy white in color and painless because nerve endings have been destroyed. Superficial epidermal (first-degree) burns are red and painful. Superficial partial-thickness and deep partial-thickness (second-degree) burns are usually blistered and painful. The patient may not realize some areas do not have pain due to the pain in the areas with more superficial burns.

Question 68.
The National Institutes for Health Stroke Scale (NIHSS) can be linked to outcomes. Which of the following indicates the meaning of the higher scoring?
(a) Better outcome
(b) Better orientation 
(c) Increased risk factors 
(d) Poorer outcome
Answer:
(d) Poorer outcome

Nursing Process: Analysis/Neurologic  

Rationale: 
The higher the score, the more the deficits are present, which indicates a worse outcome for the patient. A score of 0 would indicate no deficits present for a patient with a normal examination. The NIHSS assesses the patient’s level of consciousness, orientation, response to commands, gaze, visual fields, facial movement, motor function, limb ataxia, sensation, language, articulation, and extinction.

Question 69.
A patient was punched in the jaw. Which of the following assessment findings is consistent with mandibular fracture?
(a) Numbness to the cheek 
(b) Sublingual hematoma 
(c) Avulsed tooth
(d) Blow-out fracture
Answer:
(b) Sublingual hematoma 

Nursing Process: Assessment/Maxillofacial/Ocular 

Rationale: 
Mandibular fractures may manifest with sublingual bleeding or hematoma, trismus, malocclusion, bleeding gums, loose teeth, paresthesia of the lower lip, and ruptured tympanic membrane. Numbness to the cheek is consistent with maxillary or zygomatic fractures. Avulsed teeth occur with direct trauma to the teeth. Blow-out fracture is a fracture to the orbital floor from direct trauma to the orbit or is seen in association with LeFort, maxillary, or zygomatic fractures.

Question 70.
A 3-year-old patient is brought to the emergency department by his parents. He fell down several steps and has a fracture of the forearm. Which of the following types of fractures would be the most concerning?
(a) Epiphyseal 
(b) Transverse 
(c) Greenstick 
(d) Displaced
Answer:
(a) Epiphyseal 

Nursing Process: Analysis/Orthopedic 

Rationale: 
Fractures of the epiphyseal plate can affect healing and growth. This area is where the bones grow; thus, major problems can be expected as the child matures. While the other| would need proper care and healing, they are not as concerning as the sequelae that can occur with an epiphyseal plate injury.

Question 71.
The emergency nurse is completing an assessment for a patient with sinusitis. Which of the-following is a predisposing factor for sinusitis?
(a) Recurrent episodes of epistaxis 
(b) Recent viral upper respiratory infection 
(c) Recent fitting for dentures 
(d) Recurrent migraine headache
Answer:
(b) Recent viral upper respiratory infection 

Nursing Process: Assessment/Maxillofacial/Ocular 

Rationale: 
The most common history associated with sinusitis is recent viral upper respiratory tract infections, with up to 90% of patients having had one. A small percentage (5% to 10%) of patients have bacterial superinfection requiring antimicrobial treatment. Invasive dental procedures such as treatment for dental abscesses can be a risk factor for sinusitis; however, denture fittings are not considered to be risk factors. The patient with a migraine headache may experience sinus pain but does not constitute sinusitis. Epistaxis should be evaluated to ensure the patient does not develop a septal hematoma, which can lead to infection but is not a risk factor for sinusitis.

Question 72.
A patient presents with swelling of their lips, face, and mouth; generalized hives and itching; and tachycardia, hypotension, and generalized weakness. The history reveals that the patient was at the beach when symptoms started. Which of the following is the most likely etiology for these symptoms?
(a) A venom-specific reaction 
(b) Anaphylactic reaction to venom 
(c) Overexposure to the sun 
(d) Extracellular fluid dehydration
Answer:
(b) Anaphylactic reaction to venom 

Nursing Process: Analysis/Environmental/Shock 

Rationale: 
Although hypotension and tachycardia are also signs of venom reactions, this patient is presenting with classic anaphylaxis symptoms—hives, itching, and swelling of the face, mouth, and lips. Venom-related reactions are typically weakness and paralysis. Treatment should be aimed at the histamine reaction and circulatory collapse and should be treated as such with epinephrine, diphenhydramine (Benadryl), Hrblockers such as famotidine (Pepcid), and fluids. Overexposure to the sun would cause more heat exhaustion or heat stroke-like symptoms, including an increased temperature. The hives, itching, and swelling would not be caused by the sun exposure nor would they be associated with dehydration, although the tachycardia, hypotension, and generalized weakness could be manifestations of this process.

Question 73.
Quantitative studies are important in nursing research and utilize numeric findings for quantification. Which of the following is a true statement regarding quantitative studies?
(a) These studies compare the results of one form of treatment against a control group.
(b) This type of research gathers insight into a person’s motivations and opinions.
(c) This particular research study follows subjects with a particular disease process.
(d) This study examines relationships and determines cause and effect of variables.
Answer:
(d) This study examines relationships and determines cause and effect of variables.

Cognitive Level: Application/Professional Issues 

Rationale: 
Quantitative research (think Quantity) uses measurable data to formulate facts and uncover patterns; it examines the data to determine cause and effect. A study that compares treatments against a control group would be classified as a randomized control study in which participants are compared with a control group. Quantitative research does not necessarily follow all subjects of a specific disease process. Cohort studies follow patients over time and qualitative research (think Quality) utilizes small groups and individual insights to gather greater understanding of peoples’ opinions and motivations. It provides insights into the problem. Qualitative studies can be used to develop ideas or hypotheses for potential quantitative research.

Question 74.
A patient presents with a known history of migraine headaches. The emergency nurse prepares for which of the following treatment regimens?
(a) IV fluid bolus, antiemetic, and Morphine 
(b) IV fluid bolus, hydromorphone (Dilaudid), and antiemetic
(c) Antihistamine, antiemetic, and IV fluid bolus 
(d) Antihistamine, nitroglycerin sublingual, and IV fluid bolus
Answer:
(c) Antihistamine, antiemetic, and IV fluid bolus 

Nursing Process: Intervention/Neurologic 

Rationale: 
Over 23 million patients suffer from migraine headaches. Current treatment standards for patients with migraine headaches include providing hydration (oral or intravenous); antiemetics (ondansetron hydrochloride [Zofran]) or antihistamines (intravenous diphenhydramine [Benadryl]), and NSAIDs (ibuprofen [Motrin]). Narcotic analgesics should be avoided due to the possibility of a rebound headache and addiction. Nitroglycerin sublingual should be avoided due to the vasodilatory affect, which can increase the intensity of the headache.

Question 75.
Which of the following symptoms are indicative of measles?
(a) Pruritic rash to the chest 
(b) Bluish-gray spots on the buccal mucosa 
(c) Parotid gland enlargement
(d) Petechiae in the folds of the axilla
Answer:
(b) Bluish-gray spots on the buccal mucosa 

Nursing Process: Assessment/Communicable Diseases 

Rationale: 
Bluish-gray spots (Koplik spots) appear on the inside of the cheeks after 2 to 4 days of prodromal symptoms and are visible for up to 5 days. The rash of measles is maculopapular and first appears on the face. A pruritic rash on the chest is indicative of varicella (chickenpox). Parotid gland enlargement is characteristic of mumps. Petechiae in the skin folds of the axilla and groin are indicative of scarlet fever.

Question 76.
Which of the following is the appropriate therapeutic response in a threatening situation?
(a) Aggression
(b) Passivity 
(c) Assertiveness 
(d) Indifference
Answer:
(c) Assertiveness 

Nursing Process: Intervention/Psychosocial 

Rationale: 
Professional assertiveness is an appropriate and often effective response. Aggression is not a professional response and can escalate the circumstances. Passivity is not effective and can result in increased risk for the nurse. Indifference does not facilitate a therapeutic relationship.

Question 77.
Zovirax (Acyclovir) is the drug of choice for the treatment of genital herpes lesions. The mechanism of action includes all of the following EXCEPT:
(a) providing bactericidal functions.
(b) relieving local and systemic pain.
(c) diminishing the interval of viral shedding.
(d) decreasing the formation of new lesions.
Answer:
(a) providing bactericidal functions.

Nursing Process: Analysis/GU/GYN/OB 

Rationale: 
Herpes is a viral, not bacterial, infection (although a secondary bacterial infection can occur), and acyclovir is not bactericidal. Acyclovir relieves systemic pain, diminishes the interval of viral shedding, and decreases the formation of new lesions.

Question 78.
Which of the following statements is NOT true regarding respiratory anatomical and physiologic differences in the pediatric patient?
(a) The diaphragm is flatter and is the primary muscle for ventilation.
(b) Pediatric alveoli are larger and result in increased surface area for gas exchange.
(c) Abdominal muscles play a larger role in respiration.
(d) Children have faster and deeper respiratory rates.
Answer:
(b) Pediatric alveoli are larger and result in increased surface area for gas exchange.

Nursing Process: Analysis/Respiratory 

Rationale: 
Pediatric patients alveoli are smaller than those of an adult and results in decreased surface area for gas exchange. Pediatric patients also have increased respiratory rates which depletes limited reserves resulting in sudden decompensation. A pediatric patient’s flatter diaphragm is the primary muscle for ventilation and their abdominal muscles play a major role in respiration, meaning that abdominal trauma can impact a child’s respiratory status.

Question 79.
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.”
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 themselves warm, wear gloves, avoid smoking, and avoid cold medicines and diet pills due to 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 vasoconstriction. Fluids and aspirin would not help.

Question 80.
Which of the following interventions would NOT indicate to the emergency nurse that obstructive shock symptoms have been mitigated?
(a) Successful pericardiocentesis performed 
(b) A 3 6-week gestation patient turned to left side 
(c) 14-G cathlon inserted into second intercostal space 
(d) Bilateral normal saline boluses infusing
Answer:
(d) Bilateral normal saline boluses infusing

Nursing Process: Evaluation/Cardiovascular/Shock 

Rationale: 
Normal saline boluses would not treat an obstructive shock patient. This would be indicated in situations involving hemorrhagic or hypovolemic shock. A patient would receive a pericardiocentesis to treat a cardiac tamponade which causes obstructive shock. A pregnant patient would need to be turned to her left side in order to keep the gravid uterus off of the inferior vena cava, thus preventing or treating hypotension associated with obstructive shock. A needle decompression would be used to treat a tension pneumothorax, which would also cause obstructive shock.

Question 81.
Which of the following is the treatment of choice for a patient with a pneumothorax?
(a) Chest tube insertion
(b) Emergency thoracotomy 
(c) Needle thoracostomy 
(d) Emergent intubation
Answer:
(a) Chest tube insertion

Nursing Process: Intervention/Respiratory 

Rationale: 
A pneumothorax is treated with the insertion of a chest tube connected to an underwater seal; the tube remains in place until reexpansion of the lung is achieved. An emergency thoracotomy is reserved for a hemodynamically unstable patient. Needle thoracostomy is used in the treatment of tension pneumothorax. Most patients with a pneumothorax do not require emergent intubation.

Question 82.
The emergency nurse is discharging a patient with a probable diagnosis of Alzheimer’s versus dementia. Which of the following statements made by the family indicates an understanding of the explanations provided to them?
(a) “We understand that hallucinations and delusions are not as common as with other forms of dementia.”
(b) “We know that he is losing his mental abilities and this will interfere with his daily activities and social interactions.”
(c) “We are glad to know that there are medications out there that we will discuss with his doctor that will cure him.”
(d) “We understand that this disease called Alzheimer’s is not very common for dementia patients.”
Answer:
(b) “We know that he is losing his mental abilities and this will interfere with his daily activities and social interactions.”

Nursing Process: Evaluation/Neurologic 

Rationale: 
Alzheimer’s disease is a type of dementia. Generally, dementia is defined as a decline in thinking, reasoning, and/or remembering. People with Alzheimer’s disease have difficulty carrying out daily tasks they have performed routinely and independently throughout their lives and they can have difficulty with social interactions. Alzheimer’s disease accounts for 60% to 80% of all cases of dementia. This terminal, progressive brain disorder has no known cause or cure. Hallucinations and delusions can occur later in the disease process for these patients.

Question 83.
A patient with chronic renal failure requires multiple units of packed red blood cells. The emergency nurse should monitor the patient for:
(a) hypocalcemia.
(b) hypokalemia.
(c) increased white blood cell count.
(d) decreased clotting time.
Answer:
(a) hypocalcemia.

Nursing Process: Analysis/Medical 

Rationale: 
Each unit of packed red blood cells (PRBCs) for transfusion contains approximately 3 mg of citrate as a preservative, which accumulates in the blood where it binds to circulating calcium, thereby reducing plasma calcium concentration. Patients receiving more than 5 units of PRBCs should have serum calcium levels checked. These patients may require intravenous calcium chloride of calcium gluconate. A patient receiving multiple transfusions of PRBCs would be at risk of hyper-kalemia due to the breakdown of blood cells that releases potassium while it is being stored. White blood cell counts are not impacted with administration of packed red cells. Clotting times may be increase, because packed red cells do not contain any clotting factors. Replacement of platelets and fresh frozen plasma (FFP) should be considered when multiple units of PRBCs are infused.

Question 84.
A patient presents with postauricular pain, drooling, inability to blink one eye, and unilateral facial paralysis. Which of the following will be used to confirm the diagnosis?
(a) Facial radiograph 
(b) Electromyography (EMG)
(c) Computed tomography (CT)
(d) Clinical presentation
Answer:
(d) Clinical presentation

Nursing Process: Analysis/Maxillofacial/Ocular 

Rationale: 
There is no definitive diagnostic test to confirm Bell’s palsy, and diagnosis is confirmed based on clinical presentation of the hallmark signs and symptoms. Facial radiology may confirm bone deformities and masses in the sinuses. Computed tomography (CT) is used to rule out intracranial bleed, but does not confirm the diagnosis of Bell’s palsy. Electromyography (EMG) is used as part of the comprehensive evaluation to assess nerve and motor function.

Question 85.
A patient presents to triage after splashing drain cleaner in the eyes. The priority intervention for the emergency nurse is to:
(a) assess visual acuity.
(b) patch the affected eye(s).
(c) initiate eye flushing.
(d) initiate ophthalmology consult.
Answer:
(c) initiate eye flushing.

Nursing Process: Intervention/Maxillofacial/Ocular 

Rationale: 
Immediate intervention is to irrigate the eye with normal saline or lactated ringer solution to stop the burning and minimize permanent damage to the eye. The longer the substance remains in contact with the eye, the more damage will occur. Alkali substances may require up to 1 hour of flushing to neutralize the substance. Assessments and interventions, which may delay eye flushing, should be deferred or done concurrently with eye flushing. A detailed assessment should occur after eye flushing. There is no therapeutic value to patching the eye in the case of ocular burns. Systemic analgesics and topical cycloplegic drops may be administered, and ophthalmology will be consulted yet neither intervention should delay eye flushing.

Question 86.
A patient with an open fracture of the elbow is now experiencing a fever of 101.6° F (38.7° C) and has yellowish drainage from the site. Which of the following organisms would be expected for this type of infectious process?
(a) Staphylococcus aureus 
(b) Escherichia coli 
(c) Streptococcus agalactiae 
(d) Serratia marcescens
Answer:
(a) Staphylococcus aureus 

Nursing Process: Analysis/Orthopedic 

Rationale: 
Osteomyelitis is an infection of the bone, most often as a result of an open fracture with direct contamination. Staphylococcus aureus is found on human skin and is the main causative bacteria. Escherichia coli and Streptococcus agalactiae are common in the gastrointestinal tract and Serratia marcescens is found in water.

Question 87.
Which of the following is the most appropriate treatment for a stable patient with an open pneumothorax?
(a) Immediate chest tube insertion 
(b) Emergency thoracotomy 
(c) Autotransfusion 
(d) Intravenous dextrose 5% in water
Answer:
(a) Immediate chest tube insertion 

Nursing Process: Intervention/Respiratory 

Rationale: 
If the patient’s vital signs are stable with no signs of shock, the most appropriate intervention is chest tube insertion for reexpansion of the lung. If the patient is unstable, an emergency thoracotomy is the definitive therapy. Autotransfusion may be used to stabilize the unstable patient until transportation to surgery. Lactated ringers solution and normal saline are the only crystalloids acceptable for administration in traumatic emergencies.

Question 88.
A patient is pacing and agitated with rapid speech and is becoming belligerent. Which of the following should be the first priority?
(a) Provide immediate safety for the patient 
(b) Offer the patient a less stimulated area to calm down
(c) Change the subject by offering the patient food 
(d) Assist the staff in caring for the other patients safety
Answer:
(a) Provide immediate safety for the patient 

Cognitive Level: Application/Professional Issues 

Rationale: 
The nurse’s own and the patient’s safety first is paramount. A less stimulating environment, offering food as a distraction, and assisting other staff members in caring for other emergency patients’ safety and well-being can be important; however, scene safety is the first priority.

Question 89.
A dopamine (Intropin) infusion has been ordered for a patient in cardiogenic shock. Which of the following is NOT a precaution for the use of this medication?
(a) Close observations for the development of tachydysrhythmias
(b) Using a patent central line for drug administration 
(c) Regular measurements to check for QRS-complex prolongation
(d) Frequent monitoring of vital signs and urine output
Answer:
(c) Regular measurements to check for QRS-complex prolongation

Nursing Process: Evaluation/Cardiovascular/Shock 

Rationale: 
Dopamine (Intropin) does not affect prolongation of the QRS complex. Dopamine can cause tachydysrhythmias, requires a central IV line for administration, and frequent monitoring of vital signs and urine output. Although dopamine can be used for cardiogenic shock, dobutamine (Dobutrex) is the preferred drug due to having less of a tendency to cause tachydysrhythmias.

Question 90.
Which of the following head injuries results in a collection of blood between the skull and the dura mater? 
(a) Subdural hematoma
(b) Subarachnoid hemorrhage 
(c) Epidural hematoma 
(d) Contusion
Answer:
(c) Epidural hematoma 

Nursing Process: Analysis/Neurologic 

Rationale:
An epidural hematoma results from blood collecting between the skull and the dura mater. A subdural hematoma is commonly caused by trauma or violent shaking (shaken baby syndrome) and results in a collection of venous blood between the dura mater and the arachnoid mater. A subarachnoid hemorrhage is a collection of blood between the pia mater and the arachnoid membrane. A contusion is a bruise on the surface of the brain.

Question 91.
A store clerk was stocking cleaning supplies when the box cutter sliced open several bottles of the cleaner. The fluid splashed over the clerk’s hands, arms, and legs. The cleaner contains hydrofluoric acid. Which of the following orders would the emergency nurse expect to be prescribed for this patient?
(a) Flush area with a prepared solution of calcium gluconate.
(b) Irrigate area with 1 liter warmed saline and report pH.
(c) Wash area with mixture of sodium bicarbonate and ringer’s lactate.
(d) Apply thin layer of water-based ointment (bacitracin) to the area. 
Answer:
(a) Flush area with a prepared solution of calcium gluconate.

Nursing Process: Intervention/Environmental 

Rationale: 
The fluoride ion in hydrofluoric acid binds with calcium ions and will continue to “burn” until neutralized with calcium gluconate. While waiting for the calcium gluconate, flushing with water will help dilute the pollution, but 1 liter will not be sufficient. The patient should be put in a running stream of water. Other chemicals will not help and the wound should not be covered with an ointment until the area has been completely treated with calcium chloride. Often a paste of calcium chloride is applied so it will continue to help treat this type of burn that is due to a localized hypocalcemia and will neutralize the fluoride ions found in this product.

Question 92.
A patient is brought to the emergency department after a suspected overdose. The patient has altered perceptions of reality, shallow respirations, dysarthria, and ataxia. The emergency nurse suspects which of the following to be the causative substance?
(a) Phencyclidine (PCP)
(b) Cannabis (marijuana)
(c) Gamma-hydroxybutyrate (GHB)
(d) Lysergic acid diethylamide (LSD)
Answer:
(c) Gamma-hydroxybutyrate (GHB)

Nursing Process: Analysis/Toxicology 

Rationale: 
Gamma-hydroxybutyrate (GHB) is a sedative/ hypnotic, which induces hallucinations and euphoria as well as more commonly associated sedation effects such as respiratory depression. Phencyclidine (PCP), cannabis (marijuana), and lysergic acid diethylamide (LSD) produce hallucinations and coordination impairment but act as stimulants, rather than depressants on the respiratory drive.    

Question 93.
A patient with scrotal pain that has been present for 2 days is admitted to the emergency department. Which of the following signs would indicate a diagnosis of epididymitis rather than testicular torsion?
(a) Hypoperfusion on testicular scan 
(b) Leukopenia on complete blood count 
(c) Bacteriuria in urinalysis 
(d) Elevated creatinine level 
Answer:
(c) Bacteriuria in urinalysis 

Nursing Process: Analysis/GU/GYN/OB 

Rationale: 
Epididymitis is suggested by hyperperfusion on the testicular scan, an elevated white blood cell count, and the presence of bacteria in the urine. Hypoperfusion or no perfusion would indicate testicular torsion. Leukopenia indicates a decrease in white blood cell count. An elevated creatinine level is an indicator of renal, not scrotal disease.

Question 94.
A patient’s laboratory results indicate a sodium value of 106 mEq/mL. Which of the following would be the primary complication for the emergency nurse to anticipate?
(a) Tetany 
(b) Seizure activity 
(c) Decreased urinary output 
(d) Profound bradycardia
Answer:
(b) Seizure activity 

Nursing Process: Analysis/Medical 

Rationale: 
Normal sodium levels range between 135 and 145 mEq/mL. When serum sodium levels fall below 120 mEq/L, symptoms of hyponatremia appear. An altered level of consciousness ranging from confusion to coma and seizures are commonly seen. Tetany is a serious complication of hypocalcemia. Decreased urinary output (less than 500 mL of urine/24 hours in an adult) is seen in both acute kidney injury and chronic renal failure. Tachycardia, not bradycardia, is seen in hyponatremia.

Question 95.
Which of the following heart rates indicate the point at which chest compressions should be initiated in the newborn?
(a) 60 beats/minute 
(b) 80 beats/minute 
(c) 100 beats/minute 
(d) 110 beats/minute
Answer:
(a) 60 beats/minute 

Nursing Process: Intervention/GU/GYN/OB

Rationale: 
The normal neonatal heart rate is 120 to 160 beats/minute. Heart rates below 60 beats/minute necessitate chest compressions and ventilatory support.

Question 96.
Which of the following is an intrarenal cause of acute kidney injury (AKI)?
(a) Episode of hypovolemia 
(b) Development of neurogenic bladder 
(c) Onset of renal calculi
(d) Nonsteroidal anti-inflammatory drugs (NSAIDs)
Answer:
(d) Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nursing Process: Analysis/Medical 

Rationale: 
Intrarenal acute kidney injury (AKI) is the result of damage to the body of the kidney due to prolonged hypoperfusion and immunologic or inflammatory processes. Chronic use of NSAIDs can be directly nephrotoxic to kidney tissue. Decreased blood flow from hypovolemia is a prerenal cause of AKI, and neurogenic bladder and renal calculi, which obstruct the flow of urine out of the bladder or kidney, are postrenal causes of AKI.

Question 97.
A patient presents with hemiplegia that started 1 hour before arrival. A computed tomography (CT) scan of the head is negative and the physician has ordered administration of tissue plasminogen activator (TPA/ Activase). The emergency nurse knows that which of the following is the maximum dose of TPA?
(a) 80 mg 
(b) 90 mg 
(c) 120 mg
(d) No maximum as the dosage is based on weight
Answer:
(c) 120 mg

Nursing Process: Intervention/Neurologic 

Rationale: 
TPA is administered as a weight-based dose of 0.9 mg/kg but with a maximum dose of 90 mg in the patient presenting with a stroke. TPA is the
only thrombolytic approved for use in stroke patients.

Question 98.
Which of the following indicates that a family member has understood instructions and education regarding their father’s situation with cardiogenic shock?
(a) “I understand that my father needs to get to the cath laboratory immediately.”
(b) “I was told that it is good that his blood pressure is so low.”
(c) “We should still be able to go on our planned cruise in 10 days.”
(d) “I heard that dad had a problem with too much oxygen getting to his cells?”
Answer:
(a) “I understand that my father needs to get to the cath laboratory immediately.”

Nursing Process: Evaluation/Cardiovascular/Shock 

Rationale: 
According to the SHOCK trial, the best possible treatment for cardiogenic shock is immediate percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). These dramatically reduce the mortality rate. It is best to provide this option within 90 minutes but can be performed as much as 12 hours later with good results. Thinking that the patient will be well enough to travel in 10 days is not realistic on the part of the adult child. Low blood pressures do not help to perfuse the patient’s body and the problem is inadequate oxygenation of the cells, not too much oxygen.

Question 99.
Urine alkalization is most likely to be considered in patients who overdose on which of the following types of medications?
(a) Sulfonylureas 
(b) Cephalosporins 
(c) Calcium channel blockers 
(d) Phosphodiesterase inhibitors
Answer:
(a) Sulfonylureas 

Nursing Process: Intervention/Toxicology 

Rationale: 
Alkalization of urine is considered effective for overdoses involving phenobarbital, sulfonylureas, formaldehyde, and salicylates. Weak acids may become ion-trapped and excreted in the urine when urine pH is increased with controlled administration of alkalizing agents. Alkalinizing the urine does not promote excretion of cephalosporins, calcium channel blockers, or phosphodiesterase inhibitors.

Question 100.
Treatment for a patient with a rib fracture includes which of the following?
(a) Placing the patient in the supine position 
(b) Taping the chest circumferentially to relieve pain 
(c) Controlling pain to assist with breathing 
(d) Forcing fluids to prevent dehydration
Answer:
(c) Controlling pain to assist with breathing 

Nursing Process: Intervention/Respiratory 

Rationale: 
Pain control for a patient with rib fractures is a priority to ensure adequate expansion of lung ” tissue and to facilitate turning, coughing, and deep breathing. The patient should be placed in high Fowler’s position to facilitate gas exchange and breathing. Avoid circumferential taping of the chest or rib belts because this predisposes the patient to atelectasis and pneumonia. The lung directly below the fractured rib is often bruised (pulmonary contusion). Fluids should be monitored closely to decrease the risk of acute respiratory distress syndrome (ARDS) which causes a noncardiac pulmonary edema.

Question 101.
A patient presents to the triage desk and states, “This is the worst headache of my life.” The patient is well known by the staff with a past history of migraine headaches and hypertension. He is vomiting on arrival. He requests to have the lights off in his room, and on assessment, the emergency nurse notes that his speech is abnormal. The patient is rubbing the back of his neck and he states that it “just hurts so much when 1 move my head down.” All of the following make this person high risk for a catastrophic event EXCEPT:
(a) intensity of the headache.
(b) pain to the posterior neck area.
(c) history of migraine headaches.
(d) speech abnormalities.
Answer:
(c) history of migraine headaches.

Nursing Process: Evaluation/Neurologic 

Rationale: 
This patient is most likely experiencing a subarachnoid hemorrhage. The history of migraine headaches is not a risk factor for this catastrophic diagnosis. Patients with subarachnoid hemorrhage often state that the headache is the most severe they have ever had. This is also a process that is a sudden onset. Often patients with cerebral aneurysms are asymptomatic until the time of bleeding. At the time of rupture, blood is forced into the subarachnoid space, causing symptoms of meningeal irritation, which would cause pain to the back of the neck when the head is moved in a forward (chin to chest) direction (nuchal rigidity). Other manifestations include nausea, vomiting, aphasia or other speech difficulties, photosensitivity, hypertension, and bradycardia. Other risk factors for this diagnosis are cocaine and amphetamine use and disease processes such as Marfan’s syndrome and sickle-cell disease.

Question 102.    
A patient with an open pneumothorax is admitted to the emergency department. A nonporous dressing was placed in the field. Which of the following findings suggests worsening of this patient’s condition?
(a) Respiratory rate of 24 breaths/minute 
(b) Decreased breath sounds on the affected side 
(c) Tracheal shift with jugular vein distension (JVD)
(d) Blood pressure of 120/80 mm Hg
Answer:
(c) Tracheal shift with jugular vein distension (JVD)

Nursing Process: Evaluation/Respiratory 

Rationale: 
The finding that suggests a worsening of the patient’s condition is a tracheal shift with jugular venous distension (JVD) which indicates a tension pneumothorax. The respiratory rate within normal limits and blood pressure of 120/80 mm Hg are acceptable outcomes. The patient will have decreased breath sounds until reexpansion of the lung has been achieved.

Question 103.
Femoral head necrosis is a complication of hip dislocation. To prevent this complication, reduction of the dislocation should occur within which of the following hours?
(a) 6 
(b) 8
(c) 10 
(d) 12
Answer:
(a) 6 

Nursing Process: Intervention/Orthopedic 

Rationale: 
Reduction of dislocations should be done as soon as possible, and within a 6-hour timeframe. Any time over 6 hours is incorrect as the longer the dislocation remains, the greater the risk of necrosis.

Question 104.
Which of the following medications is most commonly used to treat anticholinergic delirium?
(a) Naloxone (Narcan)
(b) Lithium
(c) Physostigmine (Antilirium)
(d) Atropine
Answer:
(c) Physostigmine (Antilirium)

Nursing Process: Intervention/Toxicology 

Rationale: 
Physostigmine acts by interfering with the metabolism of acetylcholine; therefore, increasing the cholinergic effects of acetylcholine in the body and reversing anticholinergic delirium. Remember that physostigmine must be given slowly because of the side effects! Naloxone is used in opiate overdose. Lithium is not used as an antidote in any scenario. Atropine is used in beta-adrenergic blocker, calcium channel blocker, and organophosphate and physostigmine poisonings.

Question 105.
A S-week-old is brought in by his parents for concern of fever and being inconsolable at home. On assessment, the emergency nurse notes that the infant is irritable, exhibits a high-pitched cry, has areas of purpura on his extremities, and has a rectal temperature of 102°F (38.9° C). Which of the following are these signs and symptoms most consistent with?
(a) Henoch-Schonlein purpura 
(b) Meningococcemia 
(c) Idiopathic thrombocytopenic purpura 
(d) Kawasaki disease
Answer:
(b) Meningococcemia 

Nursing Process: Analysis/Neurologic 

Rationale: 
Meningococcemia is a potentially life-or limb-threatening clinical entity in which the organism Neisseria meningitidis gains access to the bloodstream. It is characterized by rapid onset of petechiae and purpuric lesions and is spread by oral or nasal droplets. Additional signs and symptoms include irritability, fever/temperature instability, bleeding from puncture sites, tachycardia, poor perfusion, hypotension, gangrene, and tissue necrosis (late). Henoch-Schonlein purpura (HSP) is a disease of the skin, mucous membranes, and sometimes other organs that most commonly affects children following an infectious process such as a throat infection. 

Palpable purpura (small, raised areas of bleeding underneath the skin), joint pain, and abdominal pain can occur. Chronic kidney disease can follow this disease process. Idiopathic thrombocytopenic purpura (ITP) is a disorder affecting both children and adults that can lead to easy or excessive bruising and bleeding. The bleeding results from unusually low levels of platelets and the cells that help blood clot. Children often develop ITP after a viral infection and usually recover fully without treatment. In adults, the disorder is often long-term. 

Depending on the level of platelets, manifestations can range from minimal to potentially fatal with internal bleeding. Kawasaki disease affects children and includes fever, rash, swelling of the hands and feet, irritation and redness of the whites of the eyes, and swollen lymph glands in the neck with irritation and inflammation of the mouth, lips, and throat. The effects of Kawasaki disease are rarely serious. The acute phase of the condition commonly lasts 10 to 14 days or more. Most children recover fully. In some cases, Kawasaki disease can lead to long-term heart complications. 

Question 106.
A patient is being treated for an intentional overdose of metformin (Glucophage). Which of the following would indicate that treatment has been successfully completed?
(a) Venous pH of 7.29 
(b) Blood glucose of 60 mg/dL 
(c) Lactate level of 1.1 mmol/L 
(d) Urine output of 3.5 mL/kg/hour
Answer:
(c) Lactate level of 1.1 mmol/L 

Nursing Process: Evaluation/Toxicology 

Rationale: 
A lactate level of 1.1 mmol/L would be in the standard reference range and indicates the lactic acidosis caused by the toxicity has been resolved. Remember that biguanide antihyperglycemic agents, including metformin (Glucophage), act by inhibiting liver glucose production rather than, as other antidiabetic medications do, by decreasing cellular resistance of insulin. Therefore, biguanides only drop blood sugar to the euglycemic threshold of the body and are not commonly associated with hypoglycemic emergencies. 

They do, however, inhibit liver breakdown of lactate molecules and lead to metabolic lactic acidosis in overdoses. A venous pH of 7.29 would indicate an acidotic state and would not indicate successful treatment in this situation. Because biguanide overdose is not normally associated with hypoglycemia, a blood glucose level of 60 mg/dL would not indicate successful treatment. Although increase urine output may be present in a patient who is hyperglycemic, which is likely in a patient who has access to antidiabetic medications, it would be indicative of the condition of hyperglycemia, rather than the toxic effects of metformin (Glucophage) and would not be associated with effective treatment of the toxicity.

Question 107.
A Little League player collapses after a light pole he was standing next to was hit by lightning. Which of the following actions would be an appropriate measure after maintaining scene safety?
(a) Check immediately for long-bone fractures that need immobilization
(b) Worry about cervical spine injury when attempting to resuscitate
(c) Immediately tilt the head back opening the airway to ventilate
(d) Begin chest compressions assuming ventricular fibrillation is present
Answer:
(b) Worry about cervical spine injury when attempting to resuscitate

Nursing Process: Intervention/Environmental 

Rationale: 
An ever-present concern with electrical energy is muscle spasm caused when electricity courses through the body. Energy from the lighting can travel from the pole through the ground to the player and cause spasm of the heart, neck, and other muscles of the body. Due to this, a jaw-thrust maneuver that would protect the C-spine should be utilized to open this airway. Before starting chest compressions, one should check for a pulse and respiratory effort and not assume ventricular fibrillation. Attending to the airway would take precedence over long bone fractures or other injuries sustained.

Question 108.
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 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 109.
When evaluating parameters which of the following would have the most negative impact on a patient with a closed head injury?
(a) Blood pressure—90/42 mm Hg 
(b) Cerebral perfusion pressure—85 mm Hg 
(c) Urine output—48 mL in 1 hour 
(d) Serum osmolality—280 mOsm
Answer:
(a) Blood pressure—90/42 mm Hg 

Nursing Process: Evaluation/Neurologic 

Rationale: 
One episode of hypotension, which drops the mean arterial pressure (MAP) below 70 mm Hg can have devastating effects. The MAP should be maintained between 70 and 90 mm Hg. A blood pressure of 90/42 mm Hg creates an MAP of 58 mm Hg. In a head-injured patient, the cerebral perfusion pressure (CPP) should remain above 70 mm Hg. This is the end result of the formula, CPP = MAP - ICP. The patient in this question is within normal limits for a patient with head injury. To obtain this number, an intracranial catheter must be in place. Maintaining the serum osmolality below 320 mOsm is recommended, which is noted in this question. Urine output of 48 mL/hour is adequate output.

Question 110.
A patient presents with acute onset of right upper quadrant pain and severe nausea after eating at a local fast-food restaurant. The patient also has pain to the right subclavicular area. The pain rating is 8 out of 10. Which of the following medications would the emergency nurse anticipate to NOT be prescribed for this patient?
(a) Hydromorphone (Dilaudid)
(b) Morphine sulfate 
(c) Fentanyl (Sublimaze)
(d) Meperidine (Demerol)
Answer:
(b) Morphine sulfate 

Nursing Process: Intervention/Gastrointestinal 

Rationale: 
This patient presents with manifestations of cholecystitis. Although there is some controversy regarding this, it is thought that morphine sulfate can cause spasm of the sphincter of Oddi and increase pain. Hydromorphone (Dilaudid) and fentanyl (Sublimaze) are other common narcotic medications that are used to treat this type of pain. Meperidine (Demerol) is not used much in health care today and should not be utilized for chronic pain; however, it can be used to treat acute situations such as cholecystitis.

Question 111.
Hemophilia A is characterized by a genetic deficiency of which clotting factor?
(a) Factor IX
(b) Factor VIII 
(c) Factor XI 
(d) Factor IV
Answer:
(b) Morphine sulfate 

Nursing Process: Analysis/Medical 

Rationale: 
Hemophilia A is caused by a deficiency of functional plasma clotting factor VIII. An absence of factor IX results in hemophilia B, also called Christmas disease. Hemophilia C, or Rosenthal syndrome, is caused by a deficiency of factor XI. Factor IV is ionized calcium and is required in many stages of the coagulation cascade.

Question 112.
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 (Ttrigeminal)
(d) Cranial nerve III (Oculomotor)
Answer:
(c) Cranial nerve V (Ttrigeminal)

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 the eyeball outward, and cranial nerve VIII (Acoustic) deals with hearing and balance.

Question 113.
Benzodiazepines such as lorazepam (Ativan) are no longer considered a first-line treatment for insomnia, agitation, and delirium in older adults. According to guidelines published in 2013, “elderly patients are significantly more sensitive to the sedative effects of benzodiazepines. ” Emergency nurses know that benzodiazepines can cause which of the following?
(a) Respiratory depression 
(b) Hypoxemia 
(c) Delirium 
(d) Alcohol withdrawal
Answer:
(a) Respiratory depression 

Cognitive Level: Application/Professional Issues 

Rationale: 
Benzodiazepines can cause respiratory depression as well as systemic hypotension in elderly adults with agitation and/or delirium. Hypoxemia, delirium, and alcohol withdrawal are all potential causes of agitation/ delirium in elders that the emergency nurse should rule out.

Question 114.
A 75-year-old patient arrives with symptoms of dizziness, near syncope, shortness of breath, and chest pain. There is a history of an Implantable Electronic Device. The emergency nurse should prepare for immediate:
(a) Stat 12-lead electrocardiogram.
(b) magnet application.
(c) interrogation of the pacemaker.
(d) cardiology consult.
Answer:
(a) Stat 12-lead electrocardiogram.

Nursing Process: Intervention/Cardiovascular 

Rationale: 
All of the interventions may be required; however, an emergent 12-lead ECG and rhythm strip to determine whether the implantable cardioverter defibrillator (ICD) is functioning correctly should be done initially. The magnet inactivates the sensing function so that during magnet mode, the pacemaker will pace asynchronously. Magnet application may be done later to identify battery depletion or malfunction of the ICD. Interrogation of the ICD should be done by the emergency department, cardiology, or the device manufacturer. A consult to cardiology would be needed also.

Question 115.
Ninety percent of acute aortic dissections occur in the ascending aorta. The emergency nurse knows that the most important predisposing risk factor for this process is which of the following?
(a) Trauma 
(b) Cardiac surgery 
(c) Hypertension 
(d) Cocaine use
Answer:
(c) Hypertension 

Nursing Process: Assessment/Cardiovascular 

Rationale: 
Hypertension is the primary risk factor for acute aortic dissections seen in 72% of cases. Patients tend to be 60- to 80-year-old men and were significantly more likely to have atherosclerosis. The incidence of aortic injury is estimated between 1.5% and 2 % of patients who sustain blunt thoracic trauma. Aortic instrumentation or cardiac surgery can be complicated by aortic dissection but is reported at 2% of patients. Cocaine use, which may cause transient hypertension due to catecholamine release, accounted for 37% of dissections in a report of an inner-city population.

Question 116.
A patient with a ventriculostomy in place is noted to have an increasing intracranial pressure. Which of the following corrections would help remedy this situation?
(a) Ttirn the head to the right 
(b) Place the patient supine 
(c) Remove C-Collar on neck 
(d) Increase activity in the room
Answer:
(c) Remove C-Collar on neck 

Nursing Process: Evaluation/Neurologic 

Rationale: 
C-Collars can actually increase intracranial pressure (ICP). It is important to remove them as soon as possible once the C-spine has been appropriately cleared. This will help reduce the increasing intracranial pressure. Maintaining the head in midline position, elevating the head of the bed to 30 degrees, and keeping the room quiet and dark are all ways to help keep the intracranial pressure down. Other interventions that can assist in reducing ICP are to provide pain and sedating medications and administer osmotic diuretics. Hyperventilation should only be used as a short, temporary measure when the ICP is known to be elevated. Prophylactic hyperventilation is no longer performed.

Question 117.
Which of the following observations would indicate that a depressed patient is becoming suicidal?
(a) The patient slams the phone after speaking to a loved one.
(b) The patient refuses to eat a turkey sandwich.
(c) The patient spits on the security officer.
(d) The patient gives the nurse her favorite watch.
Answer:
(d) The patient gives the nurse her favorite watch.

Cognitive Level: Application/Professional Issues 

Rationale: 
Giving away prized possessions is an indication that the person may be considering suicide. The other options could be signs of violence, increasing hostility, or depression, but do not necessarily indicate suicidal intent.

Question 118.
The PICO acronym is often used in quantitative studies to help researchers ask focused clinical questions. The “P” in PICO refers to the “Population” or “Problem” being considered. What do the “I” and “C” represent?
(a) Intervention and Control group 
(b) Intervention and Comparison 
(c) Implementation and Considerations 
(d) Implementation and Consultation
Answer:
(d) The patient gives the nurse her favorite watch.

Cognitive Level: Recall/Professional Issues 

Rationale: 
Evidence-based models use a framework with the acronym PICO(T). These elements include Problem/Patient/Population, Intervention/Indicator, Comparison, Outcome, and (optional) Time element.

Question 119.
An adult patient with significant deep partial-thickness burns is being stabilized and the calculated amount of warmed fluid has been administered. Which of the following is the best indicator that the correct amount of fluid has been administered?
(a) The respiratory rate is 32 breaths/minute.
(b) The mean arterial pressure is 45 mm Hg.
(c) The urine output is 58 mL/hour.
(d) The pulse rate is 136 beats/minute.
Answer:
(c) The urine output is 58 mL/hour.

Nursing Process: Evaluation/Environmental 

Rationale: 
Adequate fluid resuscitation is evidenced by urine output of at least 50 mL/hour. Watching urine output is considered to be the best way to monitor fluid resuscitation now. Concern for rhabdomyolysis would increase the desired urine output to at least 100 mL/hour; however, for the adult patient an output of 50 mL or more per hour is considered adequate. The respiratory rate and pulse rate would not indicate adequate fluid resuscitation. The mean arterial pressure reading of 45 mm Hg would be present with a blood pressure of 74/30 mm Hg, which would not be a desired endpoint for fluid resuscitation.

Question 120.
Alzheimer’s disease is characterized by profound impairment of cognitive functions. Which of the following is the cause of this disorder?
(a) Destruction of motor cells in the pyramidal tracts 
(b) Metabolic disorder involving the adrenal glands 
(c) Cerebral atrophy and cellular degeneration 
(d) Degeneration of the basal ganglia
Answer:
(c) Cerebral atrophy and cellular degeneration 

Nursing Process: Evaluation/Neurologic 

Rationale: 
Alzheimer’s disease is a neurologic and degenerative disorder, resulting from cerebral atrophy and cellular degeneration. Predominating symptoms are mental status changes, increased anxiety, forgetfulness, and eventually, the inability to recognize significant others and perform activities of daily living. Destruction of motor cells in the anterior gray horns and pyramidal tracts can result in the symptoms associated with amyotrophic lateral sclerosis. Metabolic disorders may cause altered cognitive function but can be reversed by correction of the underlying problem. Degeneration of the basal ganglia is usually associated with Parkinson’s disease.

Question 121.
Which of the following would NOT be an appropriate treatment regimen for a patient with a shoulder dislocation?
(a) Application of ice
(b) Immobilization
(c) Neurovascular assessment 
(d) Application of traction splint
Answer:
(d) Application of traction splint

Nursing Process: Intervention/Orthopedic 

Rationale: 
Traction splints are utilized for stabilizing long-bone fractures, most commonly the femur. Shoulder dislocations should be immobilized with the arm close to the body with a sling. Neurovascular assessment is important for all orthopedic injuries. Ice should be applied to reduce swelling.

Question 122.
A construction worker fell from the 10th floor at work. He arrives restless with severe chest discomfort, hypotension, tachycardia, tachypnea, chest wall ecchymosis, and paraplegia. The emergency nurse anticipates which of the following plans for appropriate tests and subsequent intervention?
(a) Transesophageal echo, computed tomography (CT) scan, and surgery
(b) Echocardiography, pericardiocentesis, or pericardial window
(c) Chest radiograph, chest tube insertion, and closed-chest drainage system
(d) Chest radiograph, cover open wound, and needle thoracentesis
Answer:
(a) Transesophageal echo, computed tomography (CT) scan, and surgery

Nursing Process: Intervention/Cardiovascular 

Rationale: 
Motor vehicle crashes and falls are the most common causes of aortic injury. When the aorta is subjected to accelerating, decelerating, horizontal, or vertical traumatic forces, it may tear. Signs and symptoms include decreased level of consciousness, hypotension, tachycardia, tachypnea, chest wall ecchymosis, and paraplegia. Paraplegia can occur due to the ischemia of the anterior spinal artery which is fed by branches of the aorta. Diagnosis is suspected by history of rapid deceleration forces and chest radiograph and confirmed by arteriography, transesophageal echo, or computed tomography (CT) scan. Surgical intervention is indicated. 

Pericardial tamponade occurs most often with penetrating injury; classic signs are hypotension, distended neck veins, and muffled heart sounds, and is treated with pericardiocentesis or pericardial window. Hemothorax is an accumulation of blood in the pleural space and signs/ symptoms are dyspnea, tachypnea, chest pain, signs of shock and decreased breath sounds on the affected side; treatment is chest tube insertion and closed-chest drainage system. Tension pneumothorax would present with severe respiratory distress, diminished or absent breath sounds, hypotension, distended neck veins, and tracheal deviation. Treatment is immediately preparing for a needle thoracentesis.

Question 123.
Which of the following interventions will decrease elevated intracranial pressure (ICP)?
(a) Frequent suctioning of the airway 
(b) Administering morphine for pain 
(c) Maintaining the patient in Trendelenburg position 
(d) Administering mannitol (Osmitrol)
Answer:
(d) Administering mannitol (Osmitrol)

Nursing Process: Intervention/Neurologic 

Rationale: 
Mannitol is an osmotic diuretic that decreases intracranial pressure (ICP). Suctioning the patient’s airway should be minimized to prevent increased ICP. Morphine should be used cautiously in a patient with a head injury or increased ICP because the drug’s respiratory depressant effects are considerably enhanced in these situations. A patient with a head injury should have his head elevated 30 degrees to promote venous drainage. Placing a patient in Trendelenburg position obstructs venous return from the brain and increases ICP.

Question 124.
Cardiac tamponade occurs when blood or fluid accumulates in the pericardial sac. The emergency nurse would anticipate assisting with which of the following interventions?
(a) Needle thoracentesis 
(b) Chest tube insertion 
(c) Pericardiocentesis 
(d) Thoracotomy
Answer:
(c) Pericardiocentesis 

Nursing Process: Intervention/Cardiovascular 

Rationale: 
The accumulation of blood or fluid in the mostly nondistensible pericardial sac compresses the heart and leads to a decrease in stroke volume and cardiac output, as well as decreased venous return and cardiac filling. A pericardiocentesis may be done to temporarily decompress the heart and allow for transfer to the operating room for definitive treatment. A needle thoracentesis is treatment for a tension pneumothorax. Chest tube insertion is indicated for a loss of negative intrapleural pressure and subsequent collapse of a lung. Although a thoracotomy could be done to temporarily repair an open wound in the heart, a pericardiocentesis would be attempted first.

Question 125.
An elderly patient has an elevated temperature, restlessness, confusion, and weakness after a radioactive iodine treatment. The physician suspects thyroid storm. Which treatment option should the emergency nurse anticipate?
(a) Acetylsalicylic acid (Aspirin)
(b) Propranolol (Inderal)
(c) Atropine sulfate 
(d) Sodium bicarbonate
Answer:
(b) Propranolol (Inderal)

Nursing Process: Intervention/Medical 

Rationale: 
Propranolol is the mainstay of treatment for this problem. This will decrease the heart rate and also prevents conversion of T4 to T3. The T3 state is that state in which thyroid hormone is utilized in the cells. Propranolol can be administered orally, via nasogastric tube, or intravenously. Intravenous closing is 0.5 to 1.0 mg over a 10-minute period of time and then 1.0 to 2.0 mg every few hours depending on heart rate and blood pressure readings. Aspirin has antipyretic properties, which is usually indicated for controlling fever, but in thyroid storm, aspirin is contraindicated as it can free up more thyroid hormone in the T3 state. Atropine would increase the heart rate. Anticholinergics such as atropine are ineffective in controlling the rapid heart rate of thyroid storm, as it is a hypermetabolic state due to excessive thyroid hormone release. Sodium bicarbonate is a buffer for the acid-base system. Acidosis may develop in the patient with thyroid storm due to their hypermetabolic condition, but sodium bicarbonate is not a primary treatment of thyroid storm. 

Question 126.
A patient presents with sudden onset of deep unilateral eye pain, blurry vision, halos around lights, and nausea. The emergency nurse recognizes this ocular emergency as:
(a) ultraviolet keratitis.
(b) closed-angle glaucoma.
(c) central retinal artery occlusion.
(d) retinal detachment.
Answer:
(b) Propranolol (Inderal)

Nursing Process: Assessment/Maxillofacial/Ocular 

Rationale: 
Closed-angle also referred to as narrow-angle glaucoma, occurs when the angle between the iris and the cornea becomes blocked. The condition can lead to permanent loss of sight due to pressure on the optic nerve. Classic presentation includes painful loss of vision, blurred vision, halos around lights, photophobia, nausea, vomiting, and intense headache. The globe will feel rock hard, the cornea appears hazy, and the pupil is poorly reactive or fixed. Ultraviolet keratitis presents with local symptoms including the sensation of something in the eye, profuse tearing, photophobia, and blurred vision, yet systemic symptoms are not usually present. Central retinal artery occlusion and retinal detachment typically present with painless loss of vision.

Question 127.
Nursing care of a patient with disseminated intravascular coagulopathy (DIC) includes all of the following EXCEPT:
(a) administration of medication via intramuscular route.
(b) pressure dressings to active bleeding sites.
(c) administration of intravenous heparin.
(d) limiting the number of venipunctures.
Answer:
(a) administration of medication via intramuscular route.

Nursing Process: Intervention/Medical

Rationale: 
Intramuscular injections should be avoided to prevent bleeding and hematoma development at the injection site in a patient with disseminated intravascular coagulation (DIC). Pressure dressings will slow bleeding until the coagulopathy is corrected. Heparin is the drug of choice for treatment of DIC. It acts to inhibit thrombin development, preventing clot formation in the microvasculature. Venipunctures, injections, and other interventions that may disrupt the integrity of the skin should be avoided to prevent additional bleeding.

Question 128.
Child Protective Services has decided to remove a child from the mother’s care pending further investigation of a sexual assault on the child. The mother becomes upset and is afraid the child’s father will beat her. The nurse can refer the mother to several social service agencies. Which one of the following agencies would be most appropriate in this situation?
(a) Local women’s shelter 
(b) The welfare bureau 
(c) A homeless shelter 
(d) A soup kitchen
Answer:
(a) Local women’s shelter 

Cognitive Levels: Analysis/Professional Issues 

Rationale: 
A women’s shelter can provide many services that are necessary for the mother including safety for herself and her child while keeping her location confidential. The welfare bureau is a state agency that provides funds for food, shelter, or other necessities for people who need it. Homeless shelters and soup kitchens are voluntary organizations for people in need of shelter and food. They do not necessarily have resources to accommodate patients at risk for abuse.

Question 129.
Immunotherapy for anaphylaxis can be given to people with allergies to which of the following agents?
(a) Peanuts
(b) Insect stings 
(c) Milk 
(d) Latex
Answer:
(b) Insect stings 

Nursing Process: Intervention/Medical 

Rationale: 
Immunotherapy can provide significant improvements in allergic symptoms and reduce the need for additional pharmacotherapy of insect stings and environmental allergens such as pollen. Immunotherapy has proven to have long-term benefits and is effective for desensitizing a person as a means of preventing reactions to subsequent stings. There are clinical trials using immunotherapy in peanut allergies but it is not a proven therapy at this time. No specific immunological therapy has been found to desensitize milk or latex allergies.

Question 130.
A patient has a suspected zygomatic fracture. The emergency nurse prepares the patient for which of the following diagnostic tests that will confirm this diagnosis? 
(a) Facial ultrasound
(b) Lateral facial radiograph 
(c) Water’s view radiograph 
(d) Facial computed tomography (CT)
Answer:
(d) Facial computed tomography (CT)

Nursing Process: Analysis/Maxillofacial/Ocular 

Rationale: 
Computed tomography (CT) is the preferred diagnostic imaging for zygomatic fracture. Water’s view (occipitomental) radiographs, Caldwell’s view (occipitofrontal) radiographs, and ultrasound can be used to screen (not diagnose) for zygomatic fractures. Lateral facial radiograph is not indicated for zygomatic fracture.

Question 131.
Several victims have arrived from a chemical plant after a bomb exploded. The victims are covered with a strong-smelling liquid and have labored respirations. Which of the following actions should the emergency nurse responding take first?
(a) Prioritize patients based on the degree of respiratory distress
(b) Assess identity of chemicals the victims were exposed to
(c) Don personal protective garments 
(d) Remove the victim's clothing
Answer:
(c) Don personal protective garments 

Cognitive Level: Application/Professional Issues 

Rationale: 
The emergency nurse should be donning personal protective garments for protection before caring for these patients. All of the other answers are appropriate, but not without the nurse being safe enough to deliver care.

Question 132.
Which of the following is the definitive therapy for a patient with a massive hemothorax?
(a) Emergency thoracotomy
(b) Chest tube insertion
(c) Fluid resuscitation    
(d) Supplemental oxygenation
Answer:
(a) Emergency thoracotomy

Nursing Process: Intervention/Respiratory 

Rationale: 
The definitive treatment for a patient with a massive hemothorax is emergency thoracotomy. It is imperative to identify and repair the source of bleeding. Temporary measures to stabilize the patient include chest tube insertion and, possibly, autotransfusion, fluid resuscitation (crystalloids and colloids), and supplemental oxygenation.

Question 133.
A patient arrives with a persistent narrow, regular tachyarrhythmia causing hypotension, altered mental status, signs of shock, and ischemic chest discomfort. Which of the following is the recommended intervention? 
(a) Synchronized cardioversion starting at 50 to 100 J
(b) Vagal maneuvers, adenosine, beta-blocker, or calcium channel blocker
(c) Adenosine 6 mg rapid intravenous push, followed with a 20-mL normal saline flush.
(d) Amiodarone 150 mg over 10 minutes, repeat as needed
Answer:
(a) Synchronized cardioversion starting at 50 to 100 J

Nursing Process: Intervention/Cardiovascular 

Rationale: 
The management of an unstable narrow-complex tachycardia is immediate synchronized cardioversion at 50 to 100 J. The American Heart Association cautions that if the symptoms are caused by the tachycardia, it is unstable and therefore, requires immediate synchronized cardioversion. Vagal maneuvers, adenosine, beta-blockers, or calcium channel blockers are recommended for stable narrow-complex tachycardias. Amiodarone of 150 mg over 10 minutes is indicated for stable wide-QRS tachycardia.

Question 134.
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 135.
When the emergency nurse approaches the patient to draw blood and the patient rolls up his sleeve and holds out his arm, this type of consent would be considered:
(a) express consent.
(b) implied consent.
(c) involuntary consent.
(d) informed consent.
Answer:
(b) implied consent.

Cognitive Level: Application/Professional Issues

Rationale: 
This voluntary physical action by the patient indicates his acceptance of the procedure and willingness to have it performed, which is considered to be implied consent.

Question 136.
Which of the following is a true statement regarding synchronized shocks?
(a) Electrical shock will be delivered as soon as the operator pushes the shock button.
(b) Caution is needed because these shocks use higher energy levels.
(c) Used for an unstable patient when polymorphic ventricular fibrillation is present 
(d) The actual shock avoids delivery during cardiac repolarization. 
Answer:
(d) The actual shock avoids delivery during cardiac repolarization. 

Nursing Process: Intervention/Cardiovascular 

Rationale: 
Synchronized cardioversion uses a sensor to deliver a shock that avoids delivery during cardiac repolarization, a period of vulnerability during which a shock can precipitate ventricular fibrillation. There will likely be a delay before the defibrillator delivers a synchronized shock because the device will look for the peak of the R wave in the QRS complex and avoid cardiac repolarization, represented by the T wave on the electrocardiogram (ECG). With unsynchronized shocks, the shock will be delivered as soon as the operator pushes the shock button and these shocks should use higher energy levels. Unsynchronized shocks are recommended when polymorphic ventricular fibrillation is present. Remember to read your questions very carefully. There is a huge difference between synchronized and unsynchronized shocks! Read every word in both the stem and the options! Also, when delivering synchronized shocks, the nurse must hold the buttons down until the shock is actually delivered.

Question 137.
Which of the following pharmacologic therapies should the emergency nurse anticipate administering to a patient with thyroid storm?
(a) Aspirin
(b) Propylthiouracil (PTU)
(c) Levothyroxine (Synthroid)
(d) Morphine sulfate
Answer:
(b) Propylthiouracil (PTU)

Nursing Process: Intervention/Medical 

Rationale: 
Thyroid storm is characterized by extremes of hyperthyroidism. Propylthiouracil (PTU) blocks thyroid hormone synthesis. Fever is a common symptom in thyroid storm and should be treated with cooling measures and antipyretics. However, aspirin should be avoided as it can increase thyroid hormone levels. Levothyroxine (Synthroid) is a synthetic replacement for thyroid hormone to treat hypothyroidism, not thyroid storm. Morphine sulfate is an opioid analgesic and is not indicated in the treatment of thyroid storm.

Question 138.
Which of the following is the most appropriate intervention for a patient with chronic obstructive pulmonary disease (COPD)?
(a) Administer 100% oxygen via a non-rebreather mask. 
(b) Obtain and monitor arterial blood gas (ABG) levels.
(c) Restrict fluids to only at meal times,
(d) Place the patient in a supine position.
Answer:
(b) Obtain and monitor arterial blood gas (ABG) levels.

Nursing Process: Intervention/Respiratory 

Rationale: 
Monitoring arterial blood gas (ABG) levels is the appropriate intervention for the chronic obstructive pulmonary disease (COPD) patients. The patient with COPD has abnormal ABG levels, which may predispose him to respiratory distress. The patient is hypoxemic with hypercapnia. Oxygen should be administered at low concentrations to maintain hypoxic drive. If the Pa02 remains inadequate at low doses, the emergency nurse should increase the oxygen while continuously monitoring the patient’s respiratory status. A patient with COPD usually benefits from adequate hydration to liquefy secretions. Allow the patient to assume a position that facilitates ventilation, usually a forward-leaning high Fowler’s position.

Question 139.
The following four patients arrive at triage at the same time. Which patient should be taken to a treatment room first?
(a) A 7-year-old with a history of asthma with wheezing before arrival who now has increased respiratory rate but diminished wheezing.
(b) A 33-year-old with sickle cell anemia complaining of joint pain and lower back pain after a recent bacterial illness.
(c) A 12-year-old with a 1" (2.5 cm) laceration on his left foot from stepping on a piece of glass with bleeding controlled.
(d) A 16-year-old soccer player with a tibia-fibula deformity who has pedal and posterior tibialis pulses and capillary refill of 2 seconds.
Answer:
(a) A 7-year-old with a history of asthma with wheezing before arrival who now has increased respiratory rate but diminished wheezing.

Cognitive Level: Analysis/Professional Issues 

Rationale: 
The asthma patient is most emergent. This child may not be wheezing as air movement significantly decreases. Any problems in airway and breathing are considered life-threatening and should be seen immediately. In most cases, a patient presenting with sickle cell anemia is considered stable but urgent; this patient would be seen second. The 16-year-old with the fracture would most likely be seen third and a small foot laceration with controlled bleeding, fourth.

Question 140.
Which of the following disease processes would possibly place the patient at risk for a thermal burn to the globe?
(a) Bell’s palsy 
(b) Hyphema 
(c) Conjunctivitis 
(d) Ludwig’s angina
Answer:
(a) Bell’s palsy 

Nursing Process: Analysis/Maxillofacial/Ocular.    

Rationale: 
Thermal burns rarely involve the actual eye globe because the eyelid protects the globe. In Bell’s palsy, the patient is unable to close the eyelid, and therefore, would place the patient at risk for injury to the globe. Exophthalmos, a bulging globe associated with Grave’s disease, would also be a situation in which the globe would not be protected. A hyphema, conjunctivitis, and Ludwig’s angina would not affect the ability of the eyelid to close and protect the eye.

Question 141.
Interventions for a post-organ transplant patient coming to the emergency department complaining of a fever include all of the following EXCEPT:
(a) identification of the source of infection.
(b) placing the patient in a private room.
(c) restricting fluids and food.
(d) initiating antibiotic therapy quickly.
Answer:
(c) restricting fluids and food.

Nursing Process: Intervention/Medical 

Rationale: 
Fever can result in dehydration. Oral fluids as tolerated should be encouraged, and intravenous access should be initiated for administration of crystalloid solutions and medications. Post-transplant patients face a lifetime of taking immunosuppressant medications to prevent organ rejection. It is important to isolate the patient from others in the emergency department environment. Cultures of urine and blood and other likely sources of infection should be obtained. Antibiotics should be initiated within 1 hour of arrival in the emergency department.

Question 142.
While examining a patient who sustained a direct blow to the eye, the emergency nurse notes a tear-drop-shaped pupil. The nurse prepares interventions for which of the following?
(a) Ruptured globe 
(b) Glaucoma 
(c) Hyphema
(d) Orbital fracture
Answer:
(a) Ruptured globe 

Nursing Process: Assessment/Maxillofacial/Ocular 

Rationale: 
Globe rupture is an ophthalmic emergency caused by severe blunt or penetrating trauma to the eye and may result in permanent loss of vision. Classic presentation of ruptured globe includes a peaked or tear-drop-shaped pupil, vitreous humor leakage, enophthalmos (posterior displacement of eye due to loss of integrity), loss of vision, and pain. Glaucoma is the result of increased intraocular pressure and distinct change in pupil shape is not a classic sign. Hyphema is blood in the anterior chamber of the eye and does not result in change in pupil shape or size. Orbital fracture is a fracture of the supporting structures of the globe and does not result in change in pupil shape or size, unless accompanied by a ruptured globe.

Question 143.    
A research study involves asking a group of nurses questions regarding perception of the value of an ED-specific preceptor program versus a hospital-based preceptor program. This type of research is considered to be:
(a) qualitative.
(b) quantitative.
(c) systematic.
(d) retrospective.
Answer:
(a) qualitative.

Cognitive Level: Reckll/Professional Issues 

Rationale: 
Think “quality.” Qualitative studies involve questions related to human responses, opinions, and motivations of the participants. Quantitative studies review data. Systematic reviews involve extensive literature search and retrospective studies follow subjects over time.

Question 144.
Which of the following responses from a new emergency nurse on an orientation test would indicate knowledge of the neurologic problem related to difficulty in transforming sound into patterns of understandable speech?
(a) Receptive aphasia 
(b) Dysphagia
(c) Expressive aphasia
(d) Apraxia
Answer:
(c) Expressive aphasia

Nursing Process: Evaluation/Neurologic 

Rationale: 
The new emergency nurse would provide the correct response if she/he stated that expressive aphasia is represented by the inability to speak words even though the patient is able to comprehend the spoken word. This is indicative of stroke syndromes on the left side of the brain (right-sided hemiplegia). Receptive aphasia is an impaired ability to understand spoken words. Dysphagia refers to difficulty in swallowing, which occurs when injury affects the vertebrobasilar region. Apraxia is the inability to perform a learned movement, such as using a comb, brushing one’s teeth, or waving goodbye.

Question 145.
Which of the following objects, if lodged in a child’s nose, must be removed emergently?
(a) Plastic toy part
(b) Small disc battery
(c) Rubber pencil eraser
(d) Cashew nut
Answer:
(b) Small disc battery

Nursing Process: Intervention/Maxillofacial/Ocular 

Rationale: 
Any object in the nasal passage may become dislodged resulting in obstructed airway. A disc battery lodged in the ear or nose can cause tissue necrosis in as little as 4 hours. Organic materials such as rubber, wood, or food tend to be very irritating to the mucosa, causing symptoms earlier as compared with inorganic material such as metal or plastic items.

Question 146.
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 sign and symptoms are consistent with entrapment of extraocular 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 147.
Appropriate discharge instructions for the patient diagnosed with Bell’s palsy include which of the following?
(a) Lubricant eye drops at night 
(b) Use of ophthalmic antibiotics 
(c) Prescription for antiepileptic drugs 
(d) Bed rest until symptoms resolve
Answer:
(a) Lubricant eye drops at night 

Nursing Process: Intervention/Maxillofacial/Ocular 

Rationale: 
Bell’s palsy is caused by damage to the Facial nerve (cranial nerve VII), often from herpes virus. Treatment includes administration of antivirals, corticosteroids, analgesics, eye lubricants, and facial massage. Bell’s palsy is not caused by bacterial infection. Antiepileptic drugs are used for treatment of trigeminal neuralgia. There is no therapeutic indication for strict bed rest.

Question 148.
Which of the following actions by the emergency nurse should be questioned regarding treatment for acute angle-closure glaucoma?
(a) The nurse requests an order for an antiemetic.
(b) A stat dose of d topical beta-blocker is administered.
(c) Miotic eye drops such as pilocarpine are administered immediately upon arrival, before other medication.
(d) Stat intravenous access is obtained in preparation for administration of acetazolamide (Diamox).
Answer:
(c) Miotic eye drops such as pilocarpine are administered immediately upon arrival, before other medication.

Nursing Process: Intervention/Maxillofacial/Ocular 

Rationale: 
Pilocarpine is a cholinergic miotic which causes contraction of the ciliary muscle resulting in pupil constriction. The action facilitates the outflow of aqueous humor and subsequently decreases intraocular pressure. Pressure-induced ischemic paralysis of the ciliary muscle will prevent the medication from working; therefore, pilocarpine should be administered 1 hour after administration of other agents to decrease intraocular pressure. Nausea and vomiting will result in increased intraocular pressure; therefore, an antiemetic will be helpful. Topical beta-blockers, such as Timolol and diuretics decrease aqueous humor production.

Question 149.
A patient is being discharged after treatment for epistaxis. Which of the following statements indicates the patient understood the instructions?
(a) “I will take ibuprofen for pain from the nasal packing.”
(b) “I will avoid taking hot showers when possible.”
(c) “I will instill phenylephrine nose drops for 10 days.”
(d) “I will blow my nose to clear out scabs that form.”
Answer:
(b) “I will avoid taking hot showers when possible.”

Nursing Process: Evaluation/Maxillofacial/Ocular 

Rationale: 
Discharge instructions for patients with epistaxis include avoiding anything that may contribute to continued bleeding or rebleed. Specific precautions include use of saline nasal spray and a humidifier and taking warm showers to keep the nasal mucosa moist. They should also avoid hard-blowing or sneezing, digital manipulation, aspirin, and nonsteroidal anti-inflammatory drugs. Phenylephrine nasal spray may be used as a vasoconstrictor, yet should not be used continuously for prolonged periods of time.

Question 150.
The emergency nurse knows that the patient understood discharge instructions for an uncomplicated orbital fracture when they state:
(a) “The bruising around my eye should go away in a day or so.”
(b) “Antibiotics will be prescribed so I don’t get an infection.”
(c) “I will use warm packs for the pain.”
(d) “I will try to avoid blowing my nose.” 
Answer:
(d) “I will try to avoid blowing my nose.” 

Nursing Process: Evaluation/Maxillofacial/Ocular 

Rationale: 
An uncomplicated orbital fracture is an isolated disruption of the orbital rim following blunt trauma to the eye. The patient should minimize any actions that place pressure on the eye, such as blowing the nose, to minimize further eye injury and prevent re-injury. Periorbital bruising may take days to weeks to resolve. Antibiotics may not be prescribed if there is no disruption to the skin around the eye or involvement of the globe. Ice packs should be used to decrease swelling.

CEN Sample Test:

• CEN Sample Test 1