Environmental Emergencies CEN Questions with Rationale

Answering CEN Practice Questions can help identify areas where you need more study.

Environmental Emergencies CEN Practice Questions - CEN Questions on Environmental Emergencies.

Question 1.    
While obtaining the history from a patient who presents with multiple puncture wounds on his arm, the patient states he was “. . .fishing in the river and was bitten by a big, ugly fish with whiskers!” One of the punctures seems to have a long spine (very thin, long bone) poking out from it. Which type of aquatic creature does the emergency nurse suspect caused this injury?
(a) Shark 
(b) Jellyfish 
(c) Catfish 
(d) Fire coral
Answer:
(c) Catfish 

Rationale: 
Identifying the type of aquatic creature causing the injury will be important to determine which type of treatment is most effective. Aquatic organisms with spines/whiskers (including the catfish) cause multiple puncture wounds, release a toxin from their spines, and often leave small pieces of the spine/whiskers broken off in the wounds. Each of the other aquatic organisms has a different method of protecting itself and affecting their victim.
(Clue on test taking—Read the questions very carefully. If you read this question with an eye for detail, you will notice that the patient was fishing in the lake. The other three options would not be found in the lake!)

With the increasing number of people participating in ocean-related, activities such as skin diving, snorkeling, and beach vacations, there have been an increased number of aquatic organism injuries. One does not need to go in the water to come into contact with aquatic creatures that cause injury. Additionally, now with the ease and speed of air travel, it is possible for nurses nowhere near an ocean to encounter seawater-based organism-related injuries as patients may wait until they return home to seek medical attention. Treatment will vary depending on the type of organism, thus being able to identify the causative agent will be important for correct therapy. 

Question 2.
Which of the following would be appropriate treatment for a patient who has been stung by a catfish?
(a) Soak the area in hot water (temperature: 110° F to 115° F [43° C to 46° C]) for 60 to 90 minutes, and then explore the wound in surgery to remove the spine.
(b) Pull out the spine, soak the area in sea or salt-water solution for 30 minutes, and apply vinegar to the area.
(c) Administer diphenhydramine orally, remove the spine, cleanse with soap and water, and apply an ice pack to the area.
(d) Neutralize the nematocysts, and apply shaving cream, paste of flour, talc, or baking soda to the area and shave it.
Answer:
(a) Soak the area in hot water (temperature: 110° F to 115° F [43° C to 46° C]) for 60 to 90 minutes, and then explore the wound in surgery to remove the spine.

Rationale: 
Initially soaking the area in hot water (110° F to 115° F [43° C to 46° C]) will deactivate the venom. Surgical removal under magnification followed by vigorous irrigation with warm saline is recommended to find and wash away all broken spine pieces. The wound is usually left open to allow for drainage and less risk of overwhelming infection. Option D would be appropriate for fish with stingers. Options C and D are incorrect answers.

Aquatic Animal	Cause of injury	Also Known As (AKA)	Treatment
Biters	Wound is usually torn skin, avulsion, or deep puncture	Sharks, barracuda, octopus, moray eels, sea snakes, killer whales	Radiograph for broken teeth/bones, foreign bodies, etc. Clean and irrigate wound Generally wound is left open Antibiotics and tetanus immunization
Stingers	Nematocysts embed in skin and release venom	Jellyfish, hydrozoans, Portuguese Man of War, fire coral, sea wasps, anemones	Remove any remaining parts Prevent nematocyst activation by rinsing in salt water/saline Soak in vinegar Apply shaving cream or baking soda .paste Shave area
Spiny creatures	Puncture and release a toxin	Sting rays, scorpion fish, lion fish, sea urchins, catfish	Soak in hot water (110°-U5° F [43°-46° C]) for 60-90 min to deactivate venom Look for and remove puncturing part

Question 3.
Soft-tissue radiologic examinations may be most useful after:
(a) a tiger shark bite.
(b) exposure to a Portuguese Man of War.
(c) tangling with an octopus.
(d) an attack by a sting ray.
Answer:
(d) an attack by a sting ray.

Rationale: 
Sting rays often leave part of the stinging barb in the victim and either a soft-tissue radiograph or ultrasound is needed to determine if there is a foreign body in the wound. Although a shark bite may involve bony portions of the body, a radiograph may not be necessary based on size and location of the wound. Portuguese Man of War and octopi do not leave radi-opaque bony fragments. They leave nematocysts that are not radiopaque, so will not show up on the radiograph.

Nematocysts are small, specialized cells found in the tentacles of jellyfish and other coelenterates designed to protect themselves or paralyze prey. Each cell contains a tiny venomous barb, which when stimulated, is released into the victim, injecting a poisonous liquid. This poison subdues smaller fish, but only leads to local irritation in people when they brush against a jellyfish or even a detached piece of jellyfish.
An old wives’ tale is to urinate on the area, but actually any fluid that is not at the salinity of ocean water will actually\stimulate any nematocysts that are still stuck to the skin leading to more barbs being stimulated.

Question 4.
A patient presents with swelling of his or her lips, face, and mouth; generalized hives and itching; as well as tachycardia, hypotension, and generalized weakness. The history reveals that the patient was at the beach when the 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 
 
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), and 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 sun exposure would not cause the hives, itching, and swelling nor would they be associated with dehydration although the tachycardia, hypotension, and generalized weakness could be manifestations of this process.

Question 5.
The most commonly needed type of care related to aquatic creature injury will be related to:
(a) anaphylaxis and hypotension.
(b) paralysis and muscle weakness.
(c) infection and tissue necrosis.
(d) vomiting and bloody diarrhea.
Answer:
(c) infection and tissue necrosis.

Rationale: 
Injuries caused by aquatic organisms often take place in water that is contaminated and are punc-ture wounds (which are traditionally the wound most likely to become infected) that do not drain well. They may also have small bits of foreign body parts in them (especially if exposed to a spiny creature). Any injected venom is also irritating to the tissue; thus necrosis, infection, and ulceration are much more common.

Neutralizing toxins in wounds caused by aquatic creatures is recommended, but, more importantly, a thorough Anaphylaxis, hypotension, muscle weakness, and paralysis are concerns, but are not the most common problems. Vomiting and diarrhea are not usually associated with envenomation by aquatic creatures. 

cleansing/irrigating of the wound(s) along with prophylactic antibiotics, as well as allowing the injury to heal by secondary intention, is recommended. Also ensure the patient is updated on tetanus immunization.

Question 6.
Which of the following is the most correct statement related to aquatic organisms and risks posed to rescuers? 
(a) There is little risk to rescuers and health care providers.
(b) There is no potential risk if the animal is dead.
(c) There is high risk if stinger protection is not used. 
(d) There is low risk if alcohol is used to neutralize toxins.
Answer:
(c) There is high risk if stinger protection is not used. 

Rationale: 
Rescuers and care providers must take precautions with proper PPEs to prevent accidental exposure to retained nematocysts or tentacles containing venom. Forceps or hemostats should be utilized to remove stingers or barbs to prevent being stuck. Even dead organisms will release toxins, and alcohol typically does not neutralize venom.

Question 7.
Which of the following statements regarding injury prevention education related to aquatic organisms is correct?
(a) It is safe to pick up dead aquatic creatures with bare hands.
(b) Wearing stinger suits and gloves are important when snorkeling.
(c) Aquatic envenomation is easy to avoid if one is simply careful.
(d) Staying out of the water and on the beach will eliminate chance of envenomation.
Answer:
(b) Wearing stinger suits and gloves are important when snorkeling.

Rationale: 
Appropriate protection, such as footwear, gloves, and even some kind of skin covering to prevent injury, is recommended when in the water, as is shuffling one’s feet when walking in the sand near the water. Accidentally brushing against, or stepping on unseen aquatic organisms, and reaching into small holes where an aquatic organism is hiding are the most common ways people are injured in the water by marine creatures. Often the creatures bury themselves in the sand or are so well camouflaged that they are not easily seen and so are accidentally stepped on. “Water’s Edge” injuries are just as common when aquatic creatures wash up on the beach. Venom from dead marine creatures is just as toxic.

Question 8. 
A patient states that he “tangled with a jellyfish earlier in the day while on vacation.” He complains of severe pain where the jellyfish tentacles struck him. Which action will provide the most pain relief?
(a) Soak the area in warm water for 45 minutes.
(b) Have the patient rub the area to dislodge nematocysts.
(c) Soak the area in a solution of acetic acid 5%.
(d) Administer intravenous diphenhydramine (Benadryl).
Answer:
(c) Soak the area in a solution of acetic acid 5%.

Rationale: 
Jellyfish and other coelenterates have stingers containing toxin. Acetic acid 5% (vinegar) will inactivate the venom. Immediately rinsing with salt water, soaking in vinegar, and then shaving the area will remove the nematocysts and decrease the pain. Rubbing the affected area or pouring fresh water over it will activate the nematocysts that contain the toxin. Itching is handled with topical steroids, anesthetics, or antihistamines after nematocysts are removed and the area is cleaned.

Question 9.
Which of the following aquatic creatures releases a heat-susceptible toxin, which is deactivated by soaking the area in 110° F to 115° F (43° C to 46° C) water for 60 to 90 minutes?
(a) Jellyfish
(b) Fire coral
(c) Portuguese Man of War 
(d) Stingray
Answer:
(d) Stingray

Rationale: 
Sting rays, catfish, angelfish, sea urchins, scorpion fish, and lionfish have spinous processes or whiskers that release toxin when they puncture the skin of the victim. This venom is deactivated by soaking the area in hot (110° F to 115° F [43° C to 46° C]) water for 60 to 90 minutes. Venom from stinging marine creatures—fire coral, jellyfish, and Portuguese Man of War—is deactivated by acetic acid 5 % (vinegar).

Question 10.    
The venom of aquatic organisms will most likely cause:
(a) weakness.
(b) hemolysis.
(c) hypertension.
(d) bradycardia.
Answer:
(a) weakness.

Rationale: 
Envenomatioii by marine creatures results in muscle weakness, paresthesias, hypotension, tachycardia, seizures, and cardiac arrest. Venom may also cause anaphylaxis.

Question 11.    
A child is brought to the emergency department in the early afternoon with a fresh raccoon bite. The raccoon ran away. There are several puncture wounds and a crushing laceration of the child’s hand. Which of the following infectious agents is of highest concern?
(a) Staphylococcus 
(b) Pasteurella
(c) Rabies
(d) Clostridium
Answer:
(c) Rabies

Rationale: 
Wild animals, especially bats, and also skunks and raccoon, are the most common source of rabies. Raccoons tend to be nocturnal, so it is unusual behavior for it to be out during daylight, making the bite even more suspicious. Staphylococcus is most commonly associated with human bites, Pasteurella with cat bites, and Clostridium is not related to bites but is typically food that is bitten and ingested.

Question 12. 
A parent presents with their infant requesting a “rabies shot” because they saw a bat flying in the child’s bedroom. The emergency nurse would anticipate:
(a) reassuring the parent that unless a wound is found there is no risk of rabies.
(b) administering Rabies Immune Globulin and first dose of Rabies vaccine.
(c) setting up appointments for the series of rabies injections twice a day for 21 days.
(d) initiating prophylactic intravenous antibiotics as soon as possible.
Answer:
(b) administering Rabies Immune Globulin and first dose of Rabies vaccine.

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

Initially treating someone for rabies is carried out with Rabies Immune Globulin (RIG) and the first dose of Rabies vaccine if the patient has not been vaccinated previously. Twenty units/kg of RIG is administered as much as possible around the wound if a bite site can be identified. The rest is given IM at a distant site on the body. The patient will abo need either human diploid cell vaccine (HCDC) or rabies vaccine adsorbed (RVA) 1 mL on days 0, 3, 7, and 14, or only on days 0 and 3 if previously immunized.

Question 13. 
A patient presents after being bitten by a snake that he describes as having red, yellow, and black bands on the body and a black head. He states that several tiny punctures and scratch marks are seen at the site he was bitten. The nurse should monitor for:
(a) pain, swelling, bullae at site, and hypotension.
(b) paresthesias, dysesthesias, and respiratory distress. 
(c) localized tissue edema, redness, and necrosis.
(d) rapid onset of coagulopathy and bleeding.
Answer:
(b) paresthesias, dysesthesias, and respiratory distress. 

Rationale: 
A red, yellow, and black-banded snake that leaves punctures and scratch marks is classically a coral snake (Elapidae). The venom of a coral snake can cause paresthesias, dysesthesias (abnormal sensation), and neuromuscular blockade leading to respiratory distress. Some patients will only experience mild 'swelling and paresthesias at the bite site. Symptoms may take up to 13 hours to present. There are other harmless snakes with similar coloring; thus, it is important to know the types of snakes in your area. The other three options are more typical with a pit viper bite.

Although venomous snakes are found in almost all 50 of the United States, only about 10 to 15 deaths occur per year. The two most common types of venomous snakes are Viperidae (pit vipers and vipers, AKA rattlesnakes, timber snakes, cottonmouths, copperheads, and water moccasins) and Elapidae (coral and sea snakes). It is said that about 20% of pit viper bites (recognized by fang or puncture marks) are considered “dry” with no venom released. Typically, Viperidae venom causes pain, swelling, bruising, bullae, and local tissue damage; along with coagulopathy, hemorrhage, hypotension, shock, and death. Elapidae (coral snake) venom causes neurologic symptoms, including paresthesias, dysesthesias, and neurologic blockade that can lead to respiratory distress and arrest, although typically the reaction is mostly localized. Anaphylactic reaction to either venom is abo common.

Question 14.    
Administration of snake bite anti-venom is:
(a) risky due to the possibility of adverse reaction.
(b) dependent on identification of the type of snake.
(c) most effective if given within 6 hours of a bite.
(d) indicated in both Viperidae and Elapidae snake bites.
Answer:
(c) most effective if given within 6 hours of a bite.

Rationale: 
Snake anti-venom crotaline polyvalent immune fab (CroFab) is primarily intended for pit viper envenomations and should be administered within 4 to 6 hours of the bite. It should be used only if the patient is experiencing symptoms because the drug is expensive and up to 50% of pit viper bites do not inject venom. Adverse reactions are rare with these newer versions of anti-venom but can occur, especially, if the patient has received antivenom in the past. The manufacturer recommends being ready to treat anaphylaxis, but notes it is rarely necessary. CroFab is not indicated for coral snake bites.

Although it is not necessary to skin test for CroFab®, it is best to start tH/e administration of the intravenous drip at a slow pace for at least 20 to 30 minutes. The rate can then be increased.

Question 15.    
Which type of snake bite would require obtaining laboratory studies that includes coagulation studies, blood type, and creatinine kinase level, as well as performing serial measurements on the leg where the bite occurred?
(a) Rattlesnake
(b) Coral snake 
(c) Sea snake 
(d) Bullsnake 
Answer:
(a) Rattlesnake

Rationale: 
Crotaline snakes (pit vipers), of which rattlesnakes are one type, have a toxin that contains an enzyme and protein that causes swelling, cellular tissue damage, and coagulopathy that can lead to hemorrhage, shock, and death. As a result of the swelling and cellular disruption in the limb where the bite occurred, compartment syndrome is a frequent consequence. Monitoring for bleeding issues as well as compartment syndrome will be important. Coral and sea snake venom causes nervous system disruption. Bull snakes are harmless.

Question 16. 
Which of the following statements made by a patient treated for snake bite would indicate that he or she understands proper preventative care?
(a) “I need to have additional anti-venom injections in 3, 7, and 14 days.”
(b) “The anti-venom you gave me will keep the wound from getting infected.”
(c) “It is OK to pick up snakes as long as I grab them right behind the eyes. ”
(d) “I should always wear boots or high-top shoes when hiking in the woods. ”
Answer:
(d) “I should always wear boots or high-top shoes when hiking in the woods. ”

Rationale: 
Most snake bites occur on the ankle and lower leg when a hiker accidentally disrupts a snake’s nap. Understanding that wearing boots or high-top shoes will provide protection is a positive indicator for discharge instructions. Anti-venom does not protect from an infection a common problem with snake bites. Rabies vaccine is given on days 0, 3, 7, and 14. Snake anti-venom is given immediately and until symptoms are gone. Picking up a venomous snake is just asking for trouble, because this will irritate it and will positively make the hiker a new victim!

Question 17.    
Which of the following would be proper treatment for a victim of a snake bite?
(a) Applying a proximal tourniquet 
(b) Utilizing ice on the extremity 
(c) Administering a tetanus injection 
(d) Soaking the area in warm water
Answer:
(c) Administering a tetanus injection 

Rationale: 
Any open wound is a risk for tetanus, so ensuring the patient’s tetanus status is current is the best answer in this case. Tourniquets are not helpful and should be avoided. Ice is not advised. Applying heat will speed the spread of venom and is not recommended.

Question 18.    
Hymenoptera is an insect that leaves a venom-filled stinger in the victim. This venom frequently causes anaphylaxis. Which of the following is the most likely to pose this risk to a sensitized patient?
(a) Mosquito 
(b) Sand flea 
(c) Spider
(d) Fire ant
Answer:
(d) Fire ant

Rationale: 
Hymenoptera is the most common venomous insect and include bees, wasps, hornets, and fire ants. Forty to fifty deaths per year are attributed to anaphylaxis caused by hymenoptera stings. Although there are biting spiders that produce venom, they are not hymenoptera; neither are sand fleas or mosquitoes—even though their bites can be miserable.

People allergic to bee stings (one of the hymenoptera) should not take bee pollen to counteract local allergens. There have been documented cases of anaphylaxis as the result of this home remedy because of the pollen containing bee saliva, which seems to set off the allergic reaction.

Question 19.    
A patient presents with redness, swelling, fever, and pain in an arm that was stung by several wasps 3 days previously. This patient is most likely experiencing which of the following?
(a) Infectious cellulitis of the area and needs an oral antibiotic
(b) A delayed reaction to the wasp venom and needs anti-venom
(c) Continued IgE-mediated reaction and needs antihistamine
(d) Non-wasp bite-related and needs further investigation
Answer:
(a) Infectious cellulitis of the area and needs an oral antibiotic

Rationale: 
These findings and story fit better with an infectious process because any opening in the skin can become infected, including wasp bites. The stinger may be acting as a foreign body. Some infected wasp bites have been cultured with interesting pathogens because of where they often procure the food they eat. The story also fits better with infection than reaction, because even delayed IgE-mediated reactions typically occur within 24 hours of exposure. There is no anti-venom for wasp bites.

Question 20.    
Which of the following is the most frequently reported vector-borne illness in the United States?
(a) Tick-borne Ehrlichiosis 
(b) Rocky Mountain Spotted Fever 
(c) Lyme disease 
(d) Colorado tick fever
Answer:
(c) Lyme disease 

Rationale: 
The CDC reports a dramatic increase in the number of cases of Lyme disease (now the most common vector and sixth most reported infectious disease) and has now been found in an increasing number of states in the United States. This disease was originally thought to be only in limited areas of this country. Additionally, because the symptoms are often so vague, has stages, can have life-altering consequences, and is so easily treated, it is important to obtain a history related to possible exposure and be aware of the stages of Lyme disease.

Question 21.    
A patient diagnosed with Lyme’s disease presents with nausea and vomiting. Which stage of the disease is this patient experiencing?
(a) Stage 1 
(b) Stage 2 
(c) Stage 3
(d) Stage 4
Answer:
(b) Stage 2 

Rationale: 
Dissemination of the disease occurs during Stage 2 of Lyme’s disease. During Stage 2, symptoms of Stage 1 cease and the patient may actually think they are cured. They may develop nausea, vomiting, and a diffuse rash (rather than the bull’s-eye rash seen in Stage 1). This typically occurs 4 to 10 weeks after the tick bite. Stage 1 of Lyme’s disease usually presents 3 to 30 days after the tick bite with flu-like symptoms (fever, chills, fatigue, body aches, headache, and the “classic” bull’s-eye rash anywhere on the body). Stage 1 symptoms go away on their own, with or without treatment. Patients who do not complete therapy will progress to Stage 2 where often symptoms are not recognized as Lyme disease, (The patient then progresses to Stage 3 (weeks to years after the bite) when symptoms can include joint pain, cardiac rhythm disturbances, neurologic problems (Bell’s palsy, meningitis, and impaired cognition), return of rash, or hepatitis. There is no Stage 4.

Stage 2 of Lyme disease can include signs of arthritis, general rash, poor motor coordination, malaise, fatigue, Bell’s palsy, and A-V blocks.

Question 22.    
A patient presents with concerns they may have contracted a tick-related illness. Which of the following pieces of information obtained from the patient would help to reduce the likelihood of tick-borne illnesses?
(a) A tick engorged to the size of a pea was found on the patient.
(b) The patient has been camping in a wooded, grassy area.
(c) The tick was found crawling around on the patient’s leg.
(d) The patient has not been outside, but his dog goes to the park.
Answer:
(c) The tick was found crawling around on the patient’s leg.

Rationale: 
The general consensus is that a tick must be latched onto the victim, feeding by sucking blood, and potentially instilling saliva into the victim for any of the disease organisms carried by ticks to be transmitted. It would not be crawling around the body. In fact, most sources say the tick must have been eating long enough to become engorged to infect the patient (Lyme’s disease transmission is thought to take up to half a day). Finding an engorged tick puts the patient at risk V,    and obtaining a history of the patient or the dog being in a grassy or wooded area places both at risk. Pets are a good vehicle for ticks to be brought inside and transferred to humans. A close “tick check” is always in order.

Question 23.    
Rocky Mountain Spotted Fever (RMSF) typically presents with a history of the patient having visited:
(a) the Rocky Mountains in Nevada.
(b) the grassy plains in Missouri.
(c) the rocky seashore in Oregon.
(d) the glacier fields in Montana.
Answer:
(b) the grassy plains in Missouri.

Rationale: 
Despite the name “Rocky Mountain Spotted Fever,” ticks, which bear the name of the disease, are found in grassy or wooded areas and typically not in rocky or icy places, or the seashore. This tick-borne disease is found in all areas of the country, but Arkansas, Missouri, North Carolina, Oklahoma, and Tennessee account for over 60% of reported cases.

Question 24. 
A patient presents with a high fever, chills, severe headache, confusion, nausea, and vomiting. You also notice a red, nonitchy rash on the patient’s wrists, palms, ankles, and feet. Which question answered in the affirmative might pinpoint the source of these symptoms best?
(a) “Have you been around someone else with these symptoms?”
(b) “Have you taken any new medications or used new soaps lately?”
(c) “Have you been out walking in an area that is grassy or wooded?”
(d) “Have you been wading in a weedy pond that has ducks lately?”
Answer:
(c) “Have you been out walking in an area that is grassy or wooded?”

Rationale:
These symptoms are consistent with Rocky Mountain Spotted Fever (RMSF)—one of the tick-borne diseases. Ticks that spread this disease hang out in grassy or wooded areas. RMSF is considered deadly if not treated early with doxycycline. The other questions will not obtain information related to risk of a tick causing the symptoms. The pond may have a parasite that causes cercarial dermatitis, which has this distribution of a rash, but no fever and is not treated with antibiotics. This would be an odd distribution for allergic reaction to medication and particularly for soap as one would expect the soap to come in contact with other parts of the body.

Question 25. 
Which of the following statements made by . a patient being discharged with a tick bite indicates the need for further instructions?
(a) “I need to get antibiotics every time I find a tick walking on me.”
(b) “When I go walking I will wear my pants tucked into my socks.”
(c) “To remove a tick—grab the head with tweezers and twist it off.”
(d) “I will use tick repellant when walking in areas with known ticks.” 
Answer:
(a) “I need to get antibiotics every time I find a tick walking on me.”

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

Be sure to instruct patients about preventing tick-borne illnesses. They can do this best by wearing light-colored clothing, long pants tucked into socks, and long-sleeved shirts. Tick bites are prone to infection because of retained mouth parts, so teach the patient to watch for signs of infection and always remember to check on tetanus status.

Question 26. 
An 8-year-old child is being evaluated for sudden onset of weakness and frequent falling. On examination, the child appears to have an acute ascending, flaccid paralysis that started 1 day before and is worsening. It is determined that the child has been restless and irritable, complaining of paresthesias, myalgias, and fatigue over the last several days. The child spent last week at camp and the mother said they pulled several ticks off the child when he came home. Which of the following is the highest possibility?
(a) Second stage of Lyme’s disease 
(b) Onset of human tick paralysis 
(c) Closed head injury 
(d) Guillain-Barre syndrome
Answer:
(b) Onset of human tick paralysis 

Rationale: 
A rare but deadly tick-related disease is tick paralysis. It is most typically seen in pets and small children and is often confused with Guillain-Barre disease because of the ascending paralysis that leads to respiratory muscle paralysis and death. The same ticks that cause Lyme disease and other tick-related diseases can produce this toxin. Lyme disease does not typically cause early neurologic symptoms. The ticks should lead one to suspect tick paralysis rather than Guillain-Barre, and the symptoms of paresthesias and myalgias are not consistent with a head injury.

In the show Emergency! Dr. Joe Early cured a case of tick paralysis in a young boy brought to the ED with these symptoms after ruling out polio. Emergency nurse Dixie McCall did the careful search and found the tick in the child’s hair.

The symptoms are related to a salivary toxin in the tick, not an infectious agent. Symptoms usually occur 2 to 7 dfiys after the tick attachment. Removal of the tick will lead to resolution of the symptoms.

Question 27. 
A patient states he was cleaning out an old shed when he felt a sharp pain in his left hand. He then suddenly developed an aching pain in this hand, with severe abdominal pain and nausea. Based on this information, which of the following would have most likely bitten this patient? Vital signs are as follows:

Blood pressure—180/112 mm Hg 
Pulse—138 beats/minute 
Respirations—16 breaths/minute 
Pulse oximetry—97% on room air 
Temperature—98.8°F (37.1°C)

(a) Brown recluse spider 
(b) Copperhead snake 
(c) Black widow spider 
(d) Brown nose bat
Answer:
(c) Black widow spider 

Rationale: 
Black widow spiders flourish in old sheds, barns, garages, outhouses, and other dark secluded spaces. Symptoms of a bite include a sharp pinprick sensation followed by an aching pain. Other symptoms include acute abdominal pain, nausea, vomiting, hypertension, and tachycardia. Black widow venom is a neurotoxin that can take effect in as little as 30 minutes. Copperhead snake bites cause respiratory symptoms and severe pain at the site, bat bites carry a high risk for rabies that take time to develop, and brown recluse spider bites cause a necrotic bite area that can require skin grafting.

Question 28. 
A patient presents with a small area of blackened tissue on his hand that started with itching and swelling 2 days before. Purplish blisters with adjacent purpura are seen in the area. Which of the following provides the best information for diagnosis?
(a) He was piling wood when a brown recluse spider bit his hand.
(b) While cleaning an outhouse, he was bitten by a black widow spider.
(c) A rabid bat bit him while sleeping in a small one-room cabin.
(d) When walking in a grassy wooded area, he was bitten by a deer tick.
Answer:
(a) He was piling wood when a brown recluse spider bit his hand.

Rationale: 
Brown recluse spiders like wood piles and other storage areas. The bite is often painless, until the toxin starts to cause itchy vesicles, bullae, and swelling in 1 to 3 hours. Hemorrhage into the area creates a painful purpuric area, which progresses into a necrotic ulcer. None of the other bites will cause a wound or symptoms such as these.

Question 29. 
Neurotoxin released by the black widow spider can lead to:
(a) hypotension and tachycardia.
(b) urticaria and necrosis.
(c) tingling and muscle fasciculation.
(d) hemolysis and renal failure.
Answer:
(c) tingling and muscle fasciculation.

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

Even if you do not know the answer to this question, careful reading can help you! The stem states that it is a neurotoxin causing the symptoms. The only option that would match a neurotoxin would be the tingling and muscle fasciculation.

Question 30. 
Anticipated therapy for a black widow spider bite would include which of the following?
(a) Immediate debridement of area 
(b) Administration of corticosteroids 
(c) Immediate intravenous antibiotics 
(d) Anti-venom after skin testing
Answer:
(d) Anti-venom after skin testing

Rationale: 
Black widow spider anti-venom is available, although in short supply. Its biggest risk is anaphylaxis, so skin testing is recommended. Symptoms can usually be treated with opioids and benzodiazepines. Steroids have been shown to be of little use, antibiotics are not indicated unless the wound becomes infected, and there typically is no area to debride as there might be in a brown recluse bite.

Question 31. 
Which of the following pathophysiologic events occurs with frostbite-associated tissue damage?
(a) Vasodilatory capillary leak 
(b) Sludging-related thrombosis 
(c) Cardiopulmonary ice crystals 
(d) Decreased vessel permeability
Answer:
(b) Sludging-related thrombosis 

Rationale: 
When frostbite occurs, the blood becomes “slushy” while surrounding tissues develop ice crystals. The slowed, and often stopped, blood flow forms clots or thromboses, which lead to further impaired cellular perfusion, ischemia, and cellular death. Although the vessels remain vasoconstrict, they become more permeable leading to edema of the tissue and further sludging. Ice crystals typically are found in peripheral areas (ears, feet, fingers, nose, and cheeks), but not in central areas.

Always remember to avoid rubbing frostbitten areas or allowing the victim to walk on frozen feet. This will cause increased damage to the tissues. Blankets should not be used directly on skin because they can cause tissue damage and sloughing.

Question 32. 
Which of the following is a true statement regarding superficial frostbite?
(a) Water-filled blisters occur.
(b) The skin is usually necrotic.
(c) There is no sensation in the area.
(d) Skin is hard and nonpliable.
Answer:
(a) Water-filled blisters occur.

Rationale: 
Both superficial and deep frostbite can cause blisters; however, superficial blisters are water-filled and deep are hemorrhagic. Deep frostbite is usually identified as having cyanotic, necrotic coloration with anesthesia to the affected area. The skin is hard, cool to the touch, and nonpliable. Superficial frostbite tissue is pale and edematous, with tingling and a burning sensation.

Question 33. 
Which of the following would be proper care for frostbitten feet?
(a) Rewarming should occur when there is no further chance of refreezing. 
(b) The feet should rest on the bottom of a basin filled with hot water.
(c) A hair dryer can be used if hot water is not available immediately.
(d) Warming should occur in 15- to 30-minute increments for 5 to 6 hours.
Answer:
(a) Rewarming should occur when there is no further chance of refreezing. 

Rationale: 
Frostbitten areas should be rewarmed only when there is no chance for refreezing. Areas of the frostbitten area should not be against basins or other objects as this can increase chances of cellular damage from ice crystals puncturing the cellular walls. Water baths should be used to thaw-frozen areas. Never use dry heat. Rapid, not slow rewarming is recommended.

Question 34. 
Which of the following statements made by a patient being discharged with frostbite would indicate a positive understanding?
(a) “I will stop using my aspirin and ibuprofen.”
(b) “I will continue to wear tightly fitting stockings.”
(c) “I will drink more coffee to help healing.”
(d) “I will keep my feet elevated to heart level.”
Answer:
(d) “I will keep my feet elevated to heart level.”

Rationale: 
Patients who have had frostbite will need to be on bed rest with their feet at heart level to promote circulation to and from the feet. The toes need padding between them and a loose dressing applied to prevent any pressure to the areas that were frostbitten. Aspirin or ibuprofen is often used to improve blood flow, which was sludgy from clot formation. Caffeine causes vasoconstriction, as does smoking, so both should be discouraged.

There are now facilities using fibrinolytic to bust the tiny clots found in frostbitten patients. Some are using the intravenous approach, others intra-digital injections. Both methods report improved outcomes.

Question 35. 
A patient was found outside on a cold, rainy night. The patient is unresponsive, naked, and with skin that is cold to the touch. There are no signs of shivering, and the cardiac rhythm is slow and irregular. The 12-lead electrocardiogram (ECGj shows an extra positive deflection between the QRS complex and ST segment.
The emergency nurse would suspect which of the following core temperatures and level of hypothermia?
(a) 93° F to 95° F (35° C to 36° C), mild hypothermia 
(b) 86° F to 93° F (30° C to 34° C), moderate hypothermia
(c) 83° F to 85° F (28° C to 29° C), severe hypothermia
(d) Less than 83° F (27° C), profound hypothermia
Answer:
(b) 86° F to 93° F (30° C to 34° C), moderate hypothermia

Rationale: 
This patient is demonstrating symptoms of moderate hypothermia, especially taking into consideration where they were found. An Osborne or J-wave, an extra notching after the QRS complex, is often associated with moderate hypothermia, as is atrial fibrillation. Mildly hypothermic patients still shiver, are usually responsive, and are initially tachycardic. Severely hypothermic patients are either in ventricular fibrillation or a very slow atrial fibrillation or other slow rhythm with no spontaneous respirations. In profound hypothermia, the patient will display either pulseless electrical activity (PEA) or asystole and will appear dead with a flat electroencephalogram (if available). This is usually an irreversible stage.

Paradoxical undressing: This is a theory that as the patient’s temperature drops through the moderate hypothermic stage into severe hypothermia, loss of vascular tone occurs. This causes peripheral vasodilation and the feeling that they are flushed and hot. Thus, many times hypothermic patients are found with their clothing removed. Obviously, this cools them even further and faster.

Cold diuresis: Another finding with hypothermic patients is that vasoconstriction during the mild hypothermic state leads fluids to shunt to the core. The kidneys are not able to concentrate the urine and interpret this as fluid overload, so cold diuresis occurs. During the process of resuscitation, one must replace volume, but balance replacement against the pulmonary edema that often occurs as the result of increased vascular permeability occurring during severe hypothermic stages.

Question 36. 
A severely hypothermic patient in cardiac arrest is brought to the emergency department with CPR in progress. The cardiac monitor shows ventricular fibrillation. In addition to continuing compressions and ventilations, which of the following should the team perform?
(a) Rewarm the patient before attempting emergency drugs or defibrillation.
(b) Administer 2 mg intravenous epinephrine before defibrillation and rewarming.
(c) Defibrillate the patient once, then aggressively rewarm before further shocks.
(d) Rapidly push 500 mg amiodarone (Cordarone) intravenously while rewarming.
Answer:
(c) Defibrillate the patient once, then aggressively rewarm before further shocks.

Rationale: 
The 2015 American Heart Association (AHA) recommends immediate defibrillation (rather than wasting time to check the temperature first), start chest compressions and ventilations, gives a 1-mg dose of epinephrine, and initiate rewarming if hypothermia is suspected. Evidence related to the use of defibrillation and medications in a severely hypothermic cardiac arrest is mostly theoretical; however, repeated defibrillations do not seem to be successful until the body is warmed to 86° F (30° C). Studies have shown a standard dose of epinephrine may lead to return of spontaneous circulation. Larger doses of epinephrine have caused poorer outcomes and antiarrhythmics have not been effective until the body is warmed. (Also, the dose noted is incorrect!) There is also a theoretical concern of medicines accumulating and not being metabolized in a severely hypothermic patient, so repeated doses are not recommended.

Question 37. 
Which of the following types of medications would predispose a patient found lying unresponsive on the bathroom floor to be hypothermic?
(a) Phenothiazines 
(b) Beta-blockers 
(c) Opioids 
(d) Stool softeners
Answer:
(a) Phenothiazines 

Rationale: 
Phenothiazines, barbiturates, and neuromuscular-blocking agents decrease a person’s ability to shiver, which is the body’s method of creating heat. This predisposes them to hypothermia. None of the other options decrease the ability to shiver. 

Other factors that predispose a patient to hypothermia include being very young and very old because pediatric and geriatric patients tend to have less body fat to keep them warm. Pediatric patients also do not shiver effectively. Alcohol, trauma, diabetes, and shock also can lead to hypothermia. Patients found lying on a tile or concrete floor or on the ground will leech their body heat into that cooler mass and they will quickly become hypothermic.

Question 38. 
A shivering patient brought to the emergency department by EMS has a core temperature of 90° F (32° C). Rewarming would be most easily and effectively carried out by which of the following methods?
(a) Wrapping in a reflective blanket 
(b) Forced-air warming blanket 
(c) Warmed intravenous fluid bolus 
(d) Extracorporeal Membrane Oxygenation (ECMO)
Answer:
(a) Wrapping in a reflective blanket 

Rationale: 
This patient is only mildly hypothermic as they are still shivering and creating their own heat. Passive rewarming with the i|se of a reflective blanket similar to those used by athletes will help reflect that heat back toward the patient and is the easiest, yet still effective way to warm the patient. Forced warm air blankets can actually cause vasodilation in the extremities, mobilizing the colder blood in the periphery leading to further cooling •' in the core. Warmed IV fluid boluses are listed as part of plan for the moderately hypothermic patient but they do not transfer much heat to the person; thus, other internal warming methods (warm water lavage of thoracic cavity, etc.) are recommended. ECMO (Extracorporeal Membrane Oxygenation) is recommended for severe hypothermia.

Question 39. 
During the process of rewarming and resuscitation, it is important to monitor for “after drop.” Which of the following events can occur during this process?
(a) Blood pH drops into acidotic state due to return of circulation
(b) Drop in BP when cool blood from extremities reaches the core
(c) Potassium level drops due to reactivation of cellular activity
(d) Bradycardia recurs due to increased peripheral circulation
Answer:
(b) Drop in BP when cool blood from extremities reaches the core

Rationale: 
Rewarming shock (afterdrop) occurs when colder blood from the extremities reaches the core during the warming process. Hypotension and dysrhythmias may be prevented by warming the trunk first and then the extremities once the core temperature has risen. Metabolism is slowed during hypothermia and arterial blood gas (ABG) results often do not reflect actual pH because of the blood being warmed in the blood gas analyzer. Potassium levels typically go up with hypothermia and atrial fibrillation or ventricular fibrillation are common rewarming rhythms.

Question 40. 
A patient presents with complaints of a deep throbbing pain in his joints, especially his shoulders which has been progressively worsening over the past 2 hours. He also offers complaints of being extremely tired and is noted to have a mottled-looking skin rash with pitting edema of the extremities. Which of the following would best describe his recent activity?
(a) Hiking in the woods 
(b) Mountain climbing
(c) Cave exploring 
(d) Diving in a deep lake
Answer:
(d) Diving in a deep lake

Rationale: 
Dives to depths of 30 feet or deeper, length of time breathing compressed air from a tank, and rate of ascent to the surface are the three components that can lead to decompression sickness (the bends). This can include pain in the joints, skin, peripheral nerves, or spinal cord. Patients may also have pitting edema, itching, mottled skin rash, and excessive fatigue. In more severe cases, the patient may have respiratory distress, nervous system involvement, and signs of shock. None of the other activities would set the patient up for this disease process.

Question 41. 
Decompression sickness is caused by which of the following?
(a) Oxygen floating through the blood 
(b) Nitrogen bubbles sequestering in the joints 
(c) Carbon monoxide gathering in the tissues 
(d) Hydrogen atoms under the diaphragm
Answer:
(b) Nitrogen bubbles sequestering in the joints 

Rationale: 
Decompression sickness occurs when nitrogen, which dissolves in the tissues during the dive, expands during ascent to the surface. The expanding nitrogen bubbles put pressure on the various body parts causing symptoms. This classically occurs if the patient ascends too quickly and without allowing the nitrogen bubbles to be reabsorbed. Typically, oxygen is utilized by the body, so it does not dissolve into the tissues like nitrogen, which is not utilized. There should be no carbon monoxide involved, and hydrogen gas collecting under the diaphragm would be a different issue.

Question 42. 
A patient presents with shortness of breath, confusion, and bleeding from the ears. Friends state he was diving on a wreck when he surfaced rapidly after he had accidently jabbed his hand with a knife while prying something loose from the wreckage. Bleeding is controlled at the site. Which of the following is the first priority for this patient’s care? Vital signs are as follows:

Blood pressure—96/64 mm Hg 
Pulse—110 beats/minute 
Respiratory rate—36 breaths/minute 
Pulse oximetry—90% on room air 
Temperature—98.4° F (36.8° C)

(a) Clean and suture the laceration.
(b) Arrange for hyperbaric chamber.
(c) Assist with a needle decompression.
(d) Rapidly give 2 liters IV crystalloids. 
Answer:
(b) Arrange for hyperbaric chamber.

Rationale: 
This patient is showing signs of severe Decompression Sickness (DCS) and will need to be placed in a decompression (hyperbaric) chamber to decrease the size of the nitrogen gas bubbles and eliminate them. them. It is important to assess for a pneumothorax/tension pneumothorax and treat shock; but hypotension, respiratory distress, and neurologic symptoms are consistent with DCS type II, which requires a hyperbaric chamber. Suturing the laceration can be accomplished later because bleeding is controlled at this time.

The number of hyperbaric chambers in the United States able to handle a patient suffering Decompression Sickness seems to be limited based on a survey done in 2016. Of the 361 chambers in the United States that handle hyperbaric oxygen (HBO) situations, only 43 responded that they were able to handle high-acuity patients emergently. This is important information to have on hand for those nurses who work in areas that have locations such as lakes, rivers, or water-filled mining pits with depths greater than 30 feet deep. Early identification of patients who might need these services is of great value so that calls can be expedited!

Question 43.    
On a warm, humid, summer day, the local school marching band has been practicing dress rehearsal formations for several hours. Eight of the students began complaining of dizziness and nausea. On arrival at the emergency department, all students are conscious with complaints of increased thirst, dizziness, nausea, and headaches. Active vomiting is present in four of them. They are pale and diaphoretic. What is the most likely cause of these symptoms?
(a) Heat cramps 
(b) Heat exhaustion 
(c) Heat stroke 
(d) Heat hysteria
Answer:
(b) Heat exhaustion 

Rationale: 
Altered mental status associated with nausea, vomiting, and sweating because of extreme heat is typical of heat exhaustion. The students have been creating body heat as they march; they are in uniforms that do not allow efficient cooling via passive loss of heat; high humidity makes sweating less efficient and if practicing marching formations, there will be no shade; thus, there are multiple reasons for students to develop this syndrome. Heat cramps could also develop, but symptoms for this would be muscle cramping that usually occurs in the shoulders, thighs, and abdominal wall. In heat stroke, typically the patient can be confused, ataxic, and anxious or unresponsive with hot, flushed, and dry skin, rather than actively sweating. Heat hysteria is not a documented heat-related condition.

For those patients exercising in the heat, some diaphoresis can occur. Classic or non-exertional heat stroke does present with hot, dry skin. Be aware though that just because diaphoresis is present, it does not mean it is pdf heat stroke!

Question 44. 
Which of the following would be most concerning regarding a patient diagnosed with heat stroke?
(a) Persistent lack of shivering 
(b) Pink/reddish-colored urine 
(c) Sinus tachycardia! on the monitor 
(d) Presence of a Licfitenberg Figure
Answer:
(b) Pink/reddish-colored urine 

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

Alert! Rhabdomyolysis is an important disease process that nurses should understand. It can occur for many reasons, including heat-related events such as heat stroke or heat exhaustion. Other causes are sports- related muscle injuries, status asthmaticus, status epilepticus, infections, illicit drug use such as LSD and cocaine, statins, and crush injuries (to name a few). One of the most common patients seen in the ED at risk for this is the elderly patient who has fallen, is unable to get up, and is found hours later.
One of the classic signs for this is a positive urine dipstick for blood, but no red blood cells are seen microscopically. CK (creatinine kinase) is elevated in this disease process and can be extremely high.

Question 45.    
Which of the following is the safest and most effective way to cool a patient with heat exhaustion?
(a) Covering the lower trunk with ice packs
(b) Gastric lavage with 2 L of iced saline 
(c) Utilizing fans on the patient with sprayed water 
(d) Immersing the patient into a tub of cold water
Answer:
(c) Utilizing fans on the patient with sprayed water 

Rationale: 
Wet skin with fans on is one of the most effective and efficient ways to cool someone with heat exhaustion. Ice packs can be used in areas of superficial arteries such as the groin and ankles, but covering the entire lower torso with ice and immersion tend to cause shivering that is counter-effective. Gastric lavage is an extreme measure and would only be used in critical situations. Replacing fluids and electrolytes, either orally or intravenously, is also indicated. Replacing fluids only is a major mistake in caring for these individuals.

Question 46. 
A group of nursing friends are attending a nursing conference in a mountainous area. On arrival, several of the group become irritable and are complaining of persistent headache, nausea, and extreme fatigue. There is a planned event that afternoon to the summit of one of the near mountains. Which of the following would be the best recommendation for those feeling ill?
(a) Take 1,000 mg acetaminophen, increase fluids, and attend the trip.
(b) Drink two large glasses of nonalcoholic fluids, rest, and decline the trip.
(c) Increase noncaffeinated fluids, eat some protein, and attend the trip.
(d) Eat and drink normally, go on the trip, but decline the hike.
Answer:
(b) Drink two large glasses of nonalcoholic fluids, rest, and decline the trip.

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

Both HAPE and HACE can be fatal. HAPE is a noncardiac version of pulmonary edema. Gradual ascent to high altitudes can help with acclimation and the ultimate treatment may be rapid descent to lower altitudes. For those individuals who are arriving by air to high altitudes, altitude sickness can begin the minute the doors to the airplane open. Checking pulse oximetry upon arriving can be eye-opening!! Oxygen is one of the most important treatments for these maladies.

Question 47. 
Which of the following is the primary cause of death in most submersion injuries?
(a) Aspiration 
(b) Bradycardia 
(c) Hypothermia 
(d) Hypoxia
Answer:
(d) Hypoxia

Rationale: 
Although all are comporients of and may contribute to submersion-related deaths, it is hypoxia that leads to cerebral edema and brain death, which is the primary cause of the patient’s death. Aspiration (often just a small amount of fluid) tends to initiate a cascade of events, leading to laryngospasm, pulmonary injury, and shunting that leads to further hypoxia. Bra-dycardia is the result of hypoxia and hypothermia will depend on the situation. A significant number of submersion deaths are related to small amounts of water (children falling into pails of water); thus, hypothermia is not part of the equation. A few drowning-related deaths do not take on water into the lungs because of intense laryngospasm that causes hypoxia and death.

Question 48. 
Research related to drowning outcome predictions has shown which of the following situations has the highest potential for survival?
(a) Submersion for only 5 to 10 minutes or less 
(b) Resuscitation continued for 25 minutes or greater 
(c) Circulation and breathing returned at the scene 
(d) Patient required ventilation, but no compressions
Answer:
(c) Circulation and breathing returned at the scene 

Rationale:
Obtaining a history of what happened immediately upon finding the patient is an extremely important factor in determining how long to attempt resuscitation. The need for compressions and ventilations is not an indication of poor prognosis if the patient recovers a pulse and spontaneous respirations within a short time—typically before transport. Data indicate that if resuscitation (compressions and/or ventilation) has to continue 25 minutes after removal from the water, the patient has a poor chance of survival.

There are anecdotal cases of successful resuscitation cases after 10 minutes of submersion, but studies have shown even with immediate Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) chances of recovery drop from 90 % if less than 5 minutes of submersion to 44% after 5 to 10 minutes of submersion and to 12% after 10 minutes of submersion despite resuscitative attempts unless the water was very cold. Then the patient must be warmed before terminating efforts. Death is not always immediate, but often delayed and due to multisystem organ failure or brain insult.

Question 49. 
Circulation has been restored and assisted ventilations continue in a patient rescued from a pond. Continued care will initially focus on treating which of the following disorders?
(a) Respiratory alkalosis and hypercarbia 
(b) Hypocarbia and cellular hypoxemia 
(c) Pulmonary infection and aspiration 
(d) Cerebral edema and hypothermia
Answer:
(d) Cerebral edema and hypothermia

Rationale: 
Typically, most submersion patients are hypothermic and will develop cerebral edema secondary to hypoxia. Treatment will need to focus on rewarming the patient and ensuring the brain is receiving enough oxygen by correcting pulmonary and circulation issues. The patient will show metabolic acidosis on ABG report because of altered metabolism, and although they may initially have had hypercarbia, this should correct to normal with return of circulation. Signs of extreme hypocarbia (less than 10 mm Hg) would indicate poor circulation or that the patient is being overly ventilated (less than 34 mm Hg). ETC02 levels should range from 35 to 45 mm Hg. Not all patients aspirate or develop pneumonia, and a “monitor for development” attitude is generally recommended. Ensuring the patient’s tissues are adequately oxygenated and ventilated is the focus.

Question 50. 
A patient found submerged in a cold stream has been carried into the emergency department by the family. The clothing is soaking wet. The patient mumbles when shaken, is breathing 6 breaths/minute, and has wet lung sounds. The pulse rate is 58 beats/minute and weak, skin is cool, and capillary refill is 3 seconds. Which of the following best describes priority of care for this patient?
(a) Warm to 96° F (35.6° C), intubate and apply positive end-expiratory pressure.
(b) Warm, suction fluids/debris from lungs during bronchoscopy and give diuretics, 
(c) Immobilize neck and place on Continuous Positive Airway Pressure (CPAP).
(d) Administer atropine and a vasopressor and place in postural drainage position.
Answer:
(a) Warm to 96° F (35.6° C), intubate and apply positive end-expiratory pressure.

Rationale: 
Warming and ensuring adequate ventilation and oxygenation is the priority. These actions will improve lung sounds, heart rate, and blood pressure.
Deep suctioning and diuretics, atropine, or vasopressors have not been found to be helpful. Unless history indi-cates the need to protect the neck, this action has been found to be unnecessary in most submersion injuries.
The respiratory rate is not fast enough to use Continuous Positive Airway Pressure (CPAP).

Question 51. 
A family presents to the emergency department with complaints of severe itching, especially at night. All have linear red papules, visible threadlike burrows, and excoriations at the wrists, ankles, armpits, and between their fingers and toes. Which of the following statements indicates clear understanding of the diagnosis and appropriate follow up?
(a) “This is due to tick bites. I will wear long sleeves and pants tucked into my socks when outside. ”
(b) “This is due to allergies. I won’t include strawberries or peanuts in the meals I make for my family.”
(c) “This is due to scabies. I will launder our bed linens in hot water and dry using the hottest drier cycle. ”
(d) “This is due to lice. 1 will soak all our combs, ' brushes, and hair barrettes in a 50% bleach water solution.”
Answer:
(c) “This is due to scabies. I will launder our bed linens in hot water and dry using the hottest drier cycle. ”

Rationale: 
This family has scabies based on location of itching, burrows, and excoriations. Often found in bed lines and clothing, high heat will kill scabies and their eggs. Placing nonwashable items in sealed plastic bags for 1 to 2 weeks may also kill scabies. A pediculicide that is applied to the skin may be ordered. Lice and their nits are found in the hair, tick bites can be anywhere and do not typically have burrows, and allergic reactions to food typically do not appear in this distribution.

Question 52. 
History elicits that a patient was found in a burning shed. There is black soot on the face and upper chest. Both arms and hands have blistered and peeling skin. Which of the following is the highest life-threat concern?
(a) Hypothermia due to significant skin loss 
(b) Hypovolemia due to fluid loss from burns 
(c) Electrolyte imbalance from fluid shifts 
(d) Swelling of the upper airway tissues
Answer:
(d) Swelling of the upper airway tissues

Rationale: 
Soot on the patient’s face and chest and being found in an enclosed space implies possible inhalation issues associated with breathing in of the soot and possibly heat from the fire. Both can lead to airway compromise—swelling of the upper airway and surfactant damage leading to hypoxia. Once the airway is managed, the care will need to switch to fluid volume re-placement and keeping the patient warm. Fluid shifts that affect electrolytes will occur and need to be addressed in the next 24 hours, but is not the priority issue.

Be concerned about airway compromise in patients who were in small places with the smoke and fire. Look for sooty sputum, stridor, bums to the face, and singed nasal hair and eyebrows. Hoarseness, voice changes, and/or agitation associated with signs of facial burns listed earlier should raise a red flag for the nurse to be prepared to intubate the patient. Waiting could create a situation in which - the airway closes completely and there is no chance to successfully place an endotracheal tube. Remember!!! Infants have teeny tiny tracheas! It does not take much to completely occlude their airways!!

Question 53. 
Which of the following would be a correct assumption regarding stocking-type burns on the feet or both hands on a child?
(a) This is normal as children are curious.
(b) This will require admission to a burn unit.
(c) This should raise suspicion for maltreatment.
(d) This will be treated using sulfa ointment.
Answer:
(c) This should raise suspicion for maltreatment.

Rationale: 
Burns on both hands or both feet, in a stocking pattern, or resembling a hot item should be suspicious for maltreatment and child protection should be contacted. Obtaining a consistent story as to how the injuries occurred may rule out intentional cause, but suspicion needs to occur. Not all children will require admission to the burn unit; however, follow-up with a burn center is recommended. Burns are no longer always treated with sulfa-based ointments. Water-based ointments such as bacitracin may be used, especially on the face, ears, neck, and buttocks.

Question 54. 
A store clerk was stocking cleaning supplies when the box cutter sliced off 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 ringers lactate.
(d) Apply thin layer of water-based ointment (Bacitracin) to the area.
Answer:
(a) Flush area with a prepared solution of calcium gluconate.

Rationale: 
The fluoride ion in hydrofluoric acid binds with calcium ions and will continues 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.
part of PPE includes wearing a mask to eliminate this problem. Wearing PPEs would be the priority in dealing with chemical concerns. Electrolyte changes would generally not be a concern.

Question 55. 
Which of the following is a priority risk to consider when caring for a patient presenting with a chemical burn? 
(a) Not having the proper agent needed to neutralize the chemical
(b) Creating a hazardous gas when applying water to area
(c) Exposing the caregivers to the chemical during treatment
(d) Hypokalemia when chemical is absorbed into bloodstream
Answer:
(c) Exposing the caregivers to the chemical during treatment

Rationale: 
Chemicals on patients are easily transferred to caregivers during interventions unless precautions— wearing personal protective equipment (PPE)—are taken. Neutralizing the agent is rarely indicated as dilution with large amounts of water is usually recommended for almost all chemical exposures. Sufficient water typically does not lead to issues with gas formation; however, part of PPE includes wearing a mask to eliminate this problem. Wearing PPEs would be the priority in dealing with chemical concerns. Electrolyte changes would generally not be a concern.

Question 56. 
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.

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, which 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.

Although both asystole and ventricular fibrillation can occur with a lightning strike, asystole is more common. It is thought that if ventricular fibrillation does occur, it is the result of continued hypoxia after the initial asystole converted to a sinus rhythm with subsequent deterioration to this dysrhythmia

Question 57. 
A patient presents to the emergency department after being “knocked flat” while he was playing golf.
His only complaint is that he “feels weird.” During assessment, a reddened fern-shaped pattern across his back is noted. He denies any pain to the area. Based on this presentation which of the following would be appropriate actions?
(a) Look for entrance and exit wounds 
(b) Intubate the patient to protect his airway 
(c) Check the lactate level on the patient 
(d) Monitor cardiac rhythm and urine color
Answer:
(d) Monitor cardiac rhythm and urine color

Rationale: 
Cardiac dysrhythmias and muscle contractions, leading to release of myoglobin which turns urine a pink to reddish color, are two consequences of lightening injury. Rhabdomyolysis is the outcome of this released myoglobin and can be a precursor to acute renal failure. The fern-shaped pattern is called a Lichtenberg Figure and is present for a short period of time after a lightning strike. Being “knocked flat” in conjunction with the transient hyperpigmentation on the back are good indications the patient may have sustained a lightning strike. There will be no entrance or exit wounds and the airway is generally not affected if the patient remains conscious. A lactate level would not be necessary.

Question 58. 
A patient was removed from a burning house. Which of the following would be a priority test?
(a) Pulse oximetry 
(b) 12-Lead ECG 
(c) Carboxyhemoglobin 
(d) Urine myoglobin
Answer:
(c) Carboxyhemoglobin 

Rationale: 
Incomplete combustion in a fire releases carbon monoxide (CO), which is measured with a carboxyhemoglobin (HbCO) test. High levels of CO require placement of high-flow oxygen and extremely high levels may require transfer to a hyperbaric chamber as CO leads to hypoxia and neurologic sequelae.
Pulse oximetry is inaccurate in the presence of carbon monoxide poisoning as the pulse oximetry reads that something is attached to the hemoglobin molecule but does not differentiate between oxygen and carbon monoxide. An abnormal 12 lead will not diagnose the problem (abnormalities may be seen due to cardiac cellular hypoxia). Urine myoglobin will take time to appear.

Question 59. 
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

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) are usually blistered and painful. The patient may not realize some areas do not have pain because of the pain in the areas with more superficial burns.

Question 60.    
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.

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- sis 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 61. 
Several members of an extended family visiting the area for a family reunion present with similar symptoms that began approximately 4 hours before. They complain of nausea, vomiting, trouble swallowing, crampy diarrhea, and generalized weakness. The nurse notes slurred speech, and when asked about the constant eye rubbing, the presence of blurred vision is discovered.
It also appears that eyelids are drooping slightly on several of the patients. Based on these symptoms and characteristics of the group, which of the following questions would assist in helping to diagnosis this disease process?
(a) “Have all of you eaten some of the same food?”
(b) “Were all of you playing in the hotel pool area?”
(c) “Have any of you been licked by the same dog?”
(d) “Did any of you drink the same home-made juice?”
Answer:
(a) “Have all of you eaten some of the same food?”

Rationale: 
These patients all have symptoms (trouble swallowing, thick speech, visual problems, drooping eyelids, and generalized weakness) consistent with botulism, spread by ingesting the same contaminated food. All developing symptoms at the same time is a significant clue. Diseases implied by the other questions would not include symptoms described. Legionnaires typically presents with respiratory symptoms after being in a humid area, or an area where clouds of water are spewed. Rabies involves exposure to an animal with rabies saliva. Symptoms would include tingling at bite site, flu-like symptoms, confusion, agitation, and excessive salivation. Nonpasteurized juices often contain Escherichia coli, but other foodborne illnesses including Staphylococcus aureus, Clostridium perfringens, Bacillus cereus, Campylobacter, Listeria, salmonella, and norovirus can cause abdominal pain, vomiting, fevers, and diarrhea, including bloody diarrhea.

Be suspicious any time a group of people present with similar symptoms! Consider exposure to the same bacteria or virus. Be aware of warnings posted by the local Department of Health or the CDC. Reporting multiple victims with similar symptoms may assist in controlling an outbreak. This author had to treat an entire family when a dog in the early stage of rabies was at the same family reunion and licked ice cream cones they all were eating!

Question 62. 
Which of the following would confirm a diagnosis of food poisoning? I
(a) Stool positive for blood
(b) Altered serum electrolytes 
(c) Normal white blood cell count 
(d) Sample of food ingested
Answer:
(d) Sample of food ingested

Rationale: 
Food poisoning involves the ingestion of a toxin, typically created by Staphylococcus aureus, Clostridium perfringens, or Bacillus cereus and is characterized by vomiting within 2 to 6 hours of ingesting the toxin. A sample of the toxin in the food ingested is required to make the diagnosis. Many people present stating they have “food poisoning” when, in fact, they have gastroenteritis or infectious diarrhea. Blood tests will show how the person is responding to the illness, but will not confirm the actual toxin ingested. Stool specimens would assist in the diagnosis only if the patient is infected with a bacterial, viral, parasitic, or protozoan agent. Blood in the stool alone would not diagnose these patients.

Question 63. 
A daycare provider brings three of her own children to the emergency department for evaluation of a 2-day history of abdominal pain, bloating, gas, and greasy diarrhea that floats in the toilet. Several other children from the daycare have similar symptoms. Many of the children have gluten, soy, and milk allergies/intolerances, so typically they do not eat the same foods. Which of the following is the most likely source of these symptoms?
(a) Daycare’s Golden Retriever 
(b) Gelatin snack served daily 
(c) Local community splash pad 
(d) Local park’s drinking fountain
Answer:
(c) Local community splash pad 

Rationale: 
Abdominal pain, bloating, gas, and greasy diarrhea that floats is consistent with Giardia, which most frequently is found in backcountry streams and lakes, but also can be found in municipal swimming pools, splash pads, and whirlpools. Most municipal well water is treated to prevent this; however, home wells may be contaminated. Even if the water to make gelatin is contaminated, boiling it to make the gelatin will kill Giardia. Dogs can, in theory, transmit a gastrointestinal illness to people, but dog stool would have to be ingested by the children. Giardia can also be transmitted to humans if they have been in pools or bodies of water, but in this scenario the dog was not in contact with the splash pad.

Question 64. 
Which of the following would be an appropriate response in guiding someone who is traveling to a location where the water is not guaranteed to be safe to  drink?
(a) “Use over-the-counter loperamide (Imodium) if diarrhea occurs.”
(b) “Boil all drinking water for at least 5 minutes before use.”
(c) “Avoid raw fruits, vegetables, and salads while in the country.”
(d) “Take preventative antiparasitic medications as prescribed.”
Answer:
(c) “Avoid raw fruits, vegetables, and salads while in the country.”

Rationale: 
Uncooked fruits, vegetables, and salad materials in developing nations, as well in the United States, are at risk of being contaminated by E. coli and other bacteria during the growing process and can lead to gastrointestinal illness (vomiting, diarrhea, fever, and potential life-threatening renal failure) if ingested. Washing does not always eliminate the bacterium, which is often incorporated into the structure of these foods. It is not recommended to use an anti-diarrheal as this can slow the digestive system and prolong exposure to the bacteria. Boiling water for 1 minute will kill E. coli and other bacteria. Antipara^itic agents will not help to fight against a bacterial infection.

Acids in the stomach actually kill most E. coli encountered; therefore, taking medications that decrease acids in the stomach such as omeprazole (Prilosec) or pantoprazole (Protonix), and so on, may increase the risk of developing an E. coli infection.

Question 65. 
A 2-year-old child is brought to the emergency department for evaluation of a reddened circle about an inch in diameter with an intermittent ridge line around most of the circumference on the left arm. The parents are concerned regarding the potential of ringworm as the family dog was recently treated for this. Which of the following should the emergency nurse expect if ringworm is present?
(a) A black light shined on the area that fluoresces is proof of ringworm.
(b) A social worker may be needed to investigate this type of injury.
(c) Clippings or scrapings showing bacteria will prove ringworm.
(d) The area will turn purple if swabbed with a Betadine/peroxide mixture.
Answer:
(b) A social worker may be needed to investigate this type of injury.

Rationale: 
The description of this “ring” actually fits more closely with a description of a human bite rather than ringworm and is therefore suspicious for abuse. Ringworm presents as small red, round patches that have a crusted appearance. Not all ringworm fluoresces under a black light. If this is ringworm, the clippings/ scrapings will show the fungus (scrapings are placed in a drop of potassium hydroxide [KOH] to diagnose) and will not turn purple if swabbed with Betadine and hydrogen peroxide. Ringworm is a fungus not a bacteria. (This is an actual case in which the child was bitten by another child at the day care.)

Question 66. 
Four employees at the local gardening center were unloading a truck when the forklift pierced a box of insecticide causing it to spill over all of them. Within minutes, all have classic symptoms of exposure. Which of the following symptoms would be expected with this contamination?
(a) Uncontrollable tearing and salivation.
(b) Stuffy nose and constipation
(c) Hot, dry skin and anxiety 
(d) Flushed skin and dilated pupils
Answer:
(a) Uncontrollable tearing and salivation.

Rationale: 
Insecticides cause the toxidrome associated with a cholinergic crisis. SLUDGE (Salivation, Lacrima- tion, Urination, Diarrhea, Gastrointestinal distress, and Emesis) is one mnemonic to help remember the symptoms associated with a cholinergic problem. Pupils

Toxidromes are constellations of symptoms that pinpoint a will be pinpoint and treatment continues until symptoms abate and pupils dilate. All other symptoms listed are consistent with anticholinergic agents. 

Cholinergics are wet! Anticholinergics are dry! Another mnemonic for this is MUDDLES that stands for miosis, increased urination, defecation, diaphoresis, lacrimation, excitation, and salivation. Anticholinergics cause hot, dry, flushed skin and mental status changes. A mnemonic for this process is “mad as a hatter, blind as a bat, red as a beet, hot as hades, dry as a bone. ”

Question 67. 
A tanker truck involved in a crash has several containers of cyanide that are leaking. Which of the following would the emergency department need to obtain in preparation for potential patients?
(a) Atropine and pralidoxime (2-PAM)
(b) Benzodiazepines 
(c) Hydroxocobalamin 
(d) 0.5% bleach solution
Answer:
(c) Hydroxocobalamin 

Rationale: 
One antidote for cyanide poisoning is hydroxo-cobalamin. Most medical facilities have only one to two cyanide kits, so in the process of prepping for victim arrivals, obtaining more kits would be an appropriate measure. Atropine and pralidoxime (2-PAM) are used for cholinergic crises such as might be seen with Sarin gas or other nerve agents as well as insecticides. Seizures are typically not part of symptoms associated with cyanide; therefore, benzodiazepines would not be needed and bleach is not used to treat this problem.

Question 68. 
A plumber presents after a mishap while unblocking a drain. Prior attempts involved lye and toilet bowl cleaner. A sudden eruption from the drain pipe totally drenched the plumber. On arrival to the emergency department, his clothing is still dripping with the contents of the attempts and the standing water in the pipe. Which of the following would be the first step in caring for this patient?
(a) Assist the patient in removing his shirt and pants.
(b) Douse the patient with 0.5% hypochlorite mixture. 
(c) Assist the patient in showering for 30 minutes in hot water.
(d) Obtain and don personal protective equipment. 
Answer:
(d) Obtain and don personal protective equipment. 

Rationale: 
Protecting oneself and avoiding contamina-tion by donning personal protective equipment (PPE) before helping the patient is a priority. If the patient is able to follow directions, direct him to remove his clothing and shower, but do not assist until protected from injury. More bleach (hypochlorite) will not help this situation.

Question 69. 
During a breach at a local nuclear energy plant, a radioactive was released. No explosion or radioactive dust cloud was created. Which of the following is the most important question to ask each patient as they present for treatment?
(a) “How far from the plant were you?”
(b) “Were you inside or outside a building?”
(c) “What symptoms are you having?”
(d) “Are you wearing the same clothing? ”
Answer:
(b) “Were you inside or outside a building?”

Rationale: 
Protection from radiation consists of distance, shielding, and exposure time. Patients inside buildings are more likely to be adequately protected. If they were outside, but there was a wall or structure between the patient and the blast, the risk is decreased. The farther „ away from the explosion and the shorter the exposure time, the less risk exists for the patient. Clothing is most likely not contaminated, unless the patient was involved in a dust cloud or an explosion. Lack of immediate symptoms may not indicate exposure as they may not occur for several days.

Question 70. 
Symptoms of acute radiation poisoning include which of the following?
(a) Vomiting, watery diarrhea, and fever occurring within hours
(b) Immediate painful blistering and sloughing of all exposed skin
(c) Muscle cramping, prolonged seizures, and respiratory distress
(d) Pulmonary edema, uncontrollable coughing, and tearing of eyes 
Answer:
(a) Vomiting, watery diarrhea, and fever occurring within hours

Rationale: 
Radiation sickness affects the gastrointestinal tract, blood production, and the cardiovascular/ neurologic systems. Sloughing of the gastrointestinal tract with vomiting, cramps, and diarrhea can occur within a few hours of exposure. Blood cell counts may be affected for weeks if the patient survives. The cardiovascular/neurologic system effects also include confusion and nervousness. Blistering and sloughing of skin is more consistent with exposure to a vesicant agent such as mustard gas. Cramping and seizures are consistent with nerve agents. Pulmonary edema, coughing, and tearing are associated with agents such phosgene or anhydrous ammonia.

Question 71. 
A critical tool needed during assessment of an event involving radiation release would be a/an:
(a) cardiac monitor.
(b) capnography detector.
(c) Geiger counter.
(d) glucose meter.
Answer:
(c) Geiger counter.

Rationale: 
A Geiger counter will provide evidence of radioactive materials on their body and clothing, which could cause a threat to the care providers. The knowledge of where to find and how to operate a Geiger counter will be important in an event involving radiation release. Adequate decontamination can be detected as well. The rest of the items are helpful in assessing and monitoring a patient, but do not provide information related to radiation.

Question 72. 
A 55-year-old patient was lighting the barbeque grill when it flashed over. He presents with redness and blistering of his chest, abdomen, and entire right arm and hand. Using the rule of 9’s, what percentage of body surface area is involved to be used to calculate fluid volume replacement?
(a) 7%
(b) 17%
(c) 27%
(d) 37%
Answer:
(c) 27%

Rationale: 
Using the rule of 9’s for an adult, the correct answer is 27% total body surface area (TBSA) burned. This number is reached by adding 18% for the chest/abdomen and 9% for the hand and arm. The back would be an additional 18%, each leg is 18%, the head is 9%, and the perineal area is 1 %. The other numbers are incorrect.

Other bum charts are available (Lund and Browder), which are more accurate, but initial calculation using the rule of 9’s is fast and helps to get treatment started. A really rough “guesstimate” uses the patient’s palm considering it to equal 1 % of the total body surface area. This works well, especially with smaller bums. Until recently, the Parkland formula of 2 to 4 mL x %TBSA burned x weight in kilogram was used to calculate fluid required. Recently, the American Bum Association refined this formula to also look at urine output during resuscitation with a goal of 0.5 mL/kg/hour for adults and 0.5 to 1 mL/kg/ hour for children.

Question 73. 
A behavioral health patient sticks a pilfered paper clip into the electrical wall socket in the bathroom. The staff hears a snap, sees a flash, the patient stiffens and falls to floor unresponsive, and the lights go out in the bathroom. In addition to thinking “Stabilize the ABCs,” which of the following should be considered?
(a) Percent body surface area burned 
(b) Are burns superficial or deep dermal 
(c) Immediate carboxyhemoglobin level 
(d) Look for an entrance and exit wound.
Answer:
(d) Look for an entrance and exit wound.

Rationale: 
Because the patient was holding the paperclip, there is good probability that the electricity was conducted through the patient to something wet or metal. Electrical burns often follow blood vessels or nerve pathways through the body leaving an area of char along the route inside the body. Finding the entrance and exit helps to determine the extent of the burn route. It will not be possible to determine percent of body surface burned or degree at this time. A carbon monoxide level is not indicated.

Treatment of electrical injury that has traveled through the body will include ABCs; volume replacement must be sufficient to provide a clear urine output of at least 30 to 50 mL/hour, and the patient should be monitored for cardiac dysrhythmias and compartment syndrome. Consider that the patient may be in ventricular fibrillation—the most common dysrhythmia for electrical bums!

Question 74. 
Multiple hospital staff report to the emergency department with sudden onset of severe abdominal cramping and diarrhea. Upon assessment, it is determined that all ate the “cafeteria special,” meat and gravy over noodles, earlier in the shift. All are normothermic with no vomiting. What is the anticipated action for these patients?
(a) Initiate intravenous (IV) fluids and give IV ondansetron (Zofran).
(b) Encourage increased oral fluids and rest.
(c) Determine blood type anticipating bloody diarrhea. 
(d) Administer intravenous antibiotics and admit.
Answer:
(b) Encourage increased oral fluids and rest.

Rationale: 
The “cafeteria special” probably contained Clostridium perfringens toxin that developed due to improper storage. Treatment is to replace fluids orally, unless the patient is unable to keep up with volume replacement. Meat and gravy are a common medium for this toxin, as are hospitals or similar cafeterias. Most patients do not require IV fluids and there is no reason to give ondansetron (Zofran). Typically, diarrhea does not become bloody, and this is not a bacterium that requires antibiotics, but a toxin that needs to run its course.

Question 75. 
Patients involved in environmental Emergencies present to the emergency department with a variety issues, causative factors, symptoms, and complaints. Which of the following is the priority action when providing care for an unstable victim of an unknown environmental problem?
(a) Assess to ensure airway is intact.     
(b) Check ventilation for adequacy. 
(c) Palpate skin for capillary refill.
(d) Don personal protective equipment. 
Answer:
(d) Don personal protective equipment. 

Rationale: 
Because many environmental emergencies include toxins, poisons, and other hazardous substances, it is important for emergency nurses to know what they are dealing with. Donning the appropriate PPE before coming into contact with the patient is a major priority. A healthcare provider that becomes a victim in the process of caring for patients is unable to provide care. Some may argue that an across-the-room assessment could potentially ensure the airway is intact and ventilations are adequate; however, most of the emergency nurses do not tend to run to treat the ambulatory stable person. It is the patient in trouble that emergency nurses run to help without thinking, end up contaminated, and become a victims themselves. Minimally, an “across-the-room” history will help to determine if it is safe to come into contact with a patient.