CEN Exam Questions can help you gauge your preparedness for the exam.
Maxillofacial And Ocular Emergencies CEN Practical Questions - CEN Questions On Maxillofacial And Ocular Emergencies
Question 1.
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
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, enoph-thalmos (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. If the tip of the teardrop can be seen, this is the point of perforation.
Question 2.
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.
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 the 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 admin¬istered, and ophthalmology will be consulted yet neither intervention should delay eye flushing.
Question 3.
A patient reports spontaneous painless loss of vision in one portion of the left eye and occasionally seeing flashing lights bilaterally. What additional assessment should be completed by the emergency nurse?
(a) Determine the sensation of floaters in the left eye.
(b) Inquire about unprotected eye exposure to ultraviolet light.
(c) Prepare for fluorescein examination.
(d) Assess for pupil dilation in the affected eye.
Answer:
(a) Determine the sensation of floaters in the left eye.
Rationale:
This presentation is most consistent with retinal detachment, which occurs when vitreous humor or blood seeps in-between retinal layers. The loss of sight occurs to a visual field and is painless because the retina lacks pain fibers. Photopsia (sensation of flashing light) may occur in the affected and the unaffected eye, whereas floaters (often described as black spots) occur in the affected eye. Unprotected exposure to ultraviolet light results in delayed onset of severe pain to the eyes. Fluorescein examination is indicated with suspected foreign body in the eye or corneal inconsistency. Unilateral pupil dilation may occur with narrow-angle (closed-angle) glaucoma.
Question 4.
A patient presents with unilateral painless loss of vision and is being evaluated for central retinal artery occlusion. Priority intervention by the emergency nurse includes which of the following?
(a) Digital ocular massage
(b) Patch the affected eye
(c) Facilitate mild hyperventilation
(d) Assist the patient to supine position
Answer:
(d) Assist the patient to supine position
Rationale:
Central retinal artery occlusion results from an embolus lodged in the retinal artery. Vision loss is sudden and painless. Priority interventions are geared toward restoring circulation within 90 minutes of symptom onset to prevent permanent blindness. Supine position optimizes circulation. A temporary measure of having the patient rebreathe carbondioxide (brown bag or administration of carbogen gas) may facilitate mild vasodilation.
Ocular massage should be reserved for a provider and may increase circulation or dislodge a clot. An eye patch is indicated in conditions in which eye movement is prohibited to promote healing and decrease pain. Hyperventilation will result in loss of carbon dioxide, which may result in vasoconstriction.
Question 5.
Upon examination of a patient exhibiting eye pain with extraocular movement (EOM), the emergency nurse finds pain on palpation of the sinuses and nasal quality to the voice. For which of the following conditions will the nurse continue to assess?
(a) Conjunctivitis
(b) Orbital cellulitis
(c) Iritis
(d) Uveitis
Answer:
(b) Orbital cellulitis
Rationale:
Orbital cellulitis is an infection of the soft tissues of the orbit posterior to the orbital septum. It is most commonly caused by ethmoid sinusitis. Presentation includes decreased visual acuity, proptosis (bulging eye), pain with eye movement, diffuse swelling and erythema of the lid and periorbital area, and serous discharge. The other conditions may cause eye pain, yet they are not typically associated with sinus infection.
Orbital cellulitis may result in blindness and is poten-tially life-threatening because the infection may extend into the brain. Rapid identification of the infection, in-cluding differentiation from periorbital cellulitis (prese- ptal superficial infection of the lid and periorbital area), is imperative. This is one of the patients that triage nurses must keep from leaving without being seen! It is vital that they be treated with intravenous antibiotics!
Question 6.
Which of the following statements made by a patient indicates the need for further instruction about the treatment of bacterial conjunctivitis?
(a) “I can use disposable daily contact lenses, sin'ce starting antibiotic ointment.”
(b) “I will discard all of my old eye makeup and clean my makeup brushes.”
(c) “I will avoid use of eye makeup until the infection is gone. ”
(d) “Warm compresses will help to remove discharge from my eyelids.”
Answer:
(a) “I can use disposable daily contact lenses, sin'ce starting antibiotic ointment.”
Rationale:
Contact lenses should not be worn at all during a bout with conjunctivitis. Bacterial conjunc¬tivitis is highly contagious. Infection control measures include handwashing, instillation of antibiotic ophthalmic ointment, eye cleansing procedure, avoiding use of eye makeup, and discarding previously used eye makeup.
Question 7.
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 a 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.
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, which 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 8.
A patient has purulent, yellow discharge from the eyes. The emergency nurse recognizes this presentation as being consistent with which of the following?
(a) Conjunctivitis
(b) Blepharitis
(c) Hordeolum
(d) Chalazion
Answer:
(a) Conjunctivitis
Rationale:
Conjunctivitis, also referred to as pink eye, is a bacterial or viral invasion of the conjunctiva. Classic presentation includes the sensation of something in the eye, discharge, reddened sclera, and itching. Signs and symptoms of blepharitis are similar to conjunctivitis, yet the eyelid is involved resulting in lid inflammation and pos¬sible loss of eyelashes. Hordeolum, also referred to as a sty, results in isolated abscess of an eyelid follicle. Chalazion is inflammation of the meibomian gland on the inner surface of the eyelid and presents with a mass beneath the lid.
The type of conjunctivitis can often be determined by the type of discharge. Purulent discharge is associated with bacterial infection, serous discharge is associated with viral infection and allergic reaction, and pruritis is associated with allergic reaction.
Question 9.
Which of the following is the priority intervention for a patient presenting with a penetrating foreign body eye injury?
(a) Application of an eye patch
(b) Administration of antibiotics
(c) Administration of analgesics
(d) Application of a rigid shield
Answer:
(d) Application of a rigid shield
Rationale:
Priorities of care for the person presenting with a penetrating eye injury include securing the impaled object and shielding the injured eye to minimize manipulation of the object in the eye, which will lead to further injury. Placing additional pressure on the injured eye should be avoided; there-fore, patching the eye is contraindicated. Antibiotics and analgesics will likely be indicated, yet securing the impaled object is the priority to minimize further damage to the eye.
With penetrating foreign body eye injury, the un¬affected eye should also be patched to minimize consensual movement of the eyes.
Question 10.
A patient has the appearance of bright red blood to the lateral portion of the sclera. The patient states he noticed the redness.after continuous harsh coughing yet denies recent traurAa and pain. The emergency nurse suspects this patient will be diagnosed with which of the following?
(a) Retinal hemorrhage
(b) Ultraviolet keratitis
(c) Subconjunctival hemorrhage
(d) Eight-ball hyphema
Answer:
(c) Subconjunctival hemorrhage
Rationale:
Subconjunctival hemorrhage is a benign condition that occurs when blood vessels of the conjunctiva rupture and blood is trapped between the subconjunctiva and the sclera. Some cases are idiopathic, yet it frequently occurs due to increased pressure to the area secondary to coughing, straining, forceful vomiting, or vigorous rubbing of the eye. Subconjunctival hemorrhage occurs suddenly, and other than the appearance, the patient is usually asymptomatic.
Hyphema indicates blood in the anterior chamber of the eye resulting from trauma. An eight-ball hyphema occurs when the entire anterior chamber is covered in blood. Retinal hemorrhage occurs in association with other eye injuries and/or head trauma. Both hyphema and retinal hemorrhage results in visual disturbances. Ultraviolet keratitis is a type of corneal burn, which may have delayed symptom onset from the time of the exposure to ultraviolet light.
Question 11.
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.”
Rationale:
An uncomplicated orbital fracture is an isolated disruption of the orbital rim followed by 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 reinjury. 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.
Question 12.
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
Rationale:
Facial numbness and inability to look upward are consistent with fracture to the orbital floor, also referred to as a blowout fracture. The signs and symptoms are consistent with entrapment of extraocular muscles and the infraorbital nerve, indicating a blowout 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 counts 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 13.
When assessing a patient with an eyelid laceration, the emergency nurse concludes that the patient has a deep laceration with injury to the levator muscle due to which of the following alterations?
(a) Inability to close the eyelid
(b) Inability to open the eyelid
(c) Bleeding to the eyelid
(d) Visual disturbance
Answer:
(b) Inability to open the eyelid
Rationale:
Ptosis occurs with eyelid lacerations affect¬ing the levator muscle, which is located under the upper lid, above the globe. This muscle is responsible for raising the upper lid. Bleeding may occur with any laceration and should be controlled. Visual disturbances may occur with eyelid lacerations with concurrent injury such as hyphema or globe disruption.
Protrusion of orbital fat with an associated eyelid laceration is consistent with septum involvement and injury to the levator muscle. Eyelid lacerations affecting the lacrimal structures should be repaired by an ophthalmologist.
Question 14.
A patient presents after being hit in the face with a baseball. The patient states he has “bloody vision” and assessment reveals decreased visual acuity. What other assessment data confirms the presence of a hyphema?
(a) Patient describes perception of a curtain coming down over his eye
(b) Visualization of blood covering the lower half of the iris
(c) Limitation in extraocular eye movements
(d) Severe pain when blinking the eye
Answer:
(b) Visualization of blood covering the lower half of the iris
Rationale:
Visualization of blood in the anterior chamber of the eye is the definition of a hyphema. Hyphema may occur secondary to blunt or penetrating trauma and any portion of the anterior chamber of the eye may be affected, evidenced by a blood fluid line across the iris or blacked-out appearance in an eight-ball hyphema. The patient will experience blurry vision, blood-tinged vision, pain, and decreased visual acuity. Retinal detachment gives the perception of floaters, flashing lights, or a veil or curtain across a visual field. Orbital fractures, leading to entrapment of the extraocular muscles, results in the inability to move the eye. Corneal abrasions result in pain with lid or globe movement.
A hyphema has a chance of rebleed within 2 to 5 days. This will put the patient at high risk for the development of secondary glaucoma.
Question 15.
A patient reports acute onset of loss of partial vision described as a cloudy veil over the top portion of the eye. The patient denies pain. The emergency nurse prepares for which of the following diagnostic evaluations which will confirm the diagnosis?
(a) Tonometry for intraocular pressure measurement
(b) Fluorescein stain for examination of the cornea
(c) Pupil dilation for fundal examination
(d) Computed tomography (CT) of the orbits
Answer:
(c) Pupil dilation for fundal examination
Rationale:
Painless loss of vision accompanied by the perception of floaters, flashing lights, cloudy smoky vi¬sion, or a veil or curtain over the vision are classic presentations for retinal detachment. Retinal detachment is separation of the layers of the retina and subsequent fluid or blood pooling between the retinal layers. Retinal detachment can occur spontaneously or secondary to trauma. The condition is diagnosed by dilated posterior eye examination of the fundus. Tonometry is indicated for glaucoma and iritis. Fluorescein staih is indicated for assessment of corneal irregularities such as abrasions or ulcerations. Computed tomography (CT) is indicated in orbital fracture, sinusitis, and associated facial trauma.
Question 16.
The emergency nurse is providing discharge instructions to a patient treated for corneal abrasion from contact lenses. Which of the following instructions is NOT appropriate for this patient?
(a) Instillation of topical ophthalmic antibiotic drops
(b) Avoid wearing contact lenses until reevaluation by a provider.
(c) Use of an eye patch until pain is resolved.
(d) Rest the eyes by avoiding eye strain and direct sunlight.
Answer:
(c) Use of an eye patch until pain is resolved.
Rationale:
There is no therapeutic indication for patching the eye. Corneal abrasion is a defect on the surface of the cornea. Common causes are contact lenses, foreign body in the eye, exposure to chemical irritant ip the eye, or direct scratch to the eye. Complications of corneal abrasions include infection, corneal ulceration, and delayed healing. Use of topical ophthalmic antibiotics, resting the eye, avoiding eye strain such as with computer use, and avoiding instillation of anything in the eye are important to avoid complications.
Question 17.
Which of the following does the emergency nurse prepare the patient for in the treatment of iritis?
(a) Instillation of antibiotic ophthalmic ointment
(b) Eye flush with normal saline
(c) Cold compress to the eye
(d) Instillation of ophthalmic steroids
Answer:
(d) Instillation of ophthalmic steroids
Rationale:
Iritis is an inflammatory process that may be idiopathic or secondary to systemic inflammatory disorders. Instillation of topical ophthalmic steroids and cycloplegic agents is indicated to treat the inflammation and reduce ciliary spasms. Warm compresses and resting the eye by darkening the environment is indicated. There is no therapeutic benefit of instilling antibiotic ointment or flushing the eyes, because neither of these interventions will directly decrease the inflammation.
Question 18.
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) Closed-angle glaucoma.
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.
Closed-angle glaucoma is a true ophthalmic emergency. If treatment is not initiated within hours of symptom onset, permanent blindness can occur. Open-angle glaucoma is the more common form occurring idiopathically in the geriatric population.
Question 19.
A child has a bean in the ear. Which of the following is the most appropriate initial action for the emergency nurse to implement? '
(a) Attempt to suction the bean out of the ear canal.
(b) Irrigate the ear canal with water.
(c) Use forceps to attempt removal of the bean.
(d) Apply lidocaine drops to the ear canal.
Answer:
(a) Attempt to suction the bean out of the ear canal.
Rationale:
Rubber-tipped suction is a safe effective method to attempt removal of organic foreign bodies from the ear canal. Liquids should be avoided because organic material may swell, further obstructing the ear canal. Alligator forceps may be used by an experienced provider to attempt removal of a foreign body. In this situation with a child, suction is the safer option of those presented.
Question 20.
A patient experiences hearing loss, swelling, erythema, and severe itching to the ear. The emergency nurse prepares for which of the following interventions?
(a) Insertion of an ear wick
(b) Intravenous access
(c) Otic administration of mineral oil
(d) Irrigation of the ear canal
Answer:
(a) Insertion of an ear wick
Rationale:
The symptoms suggest otitis externa, also referred to as swimmer’s ear, which is an infection of the external ear canal. An ear wick facilitates topical antibiotic administration into the swollen canal. Intravenous access may be needed for the administration of antibiotics if mastoiditis is suspected. Administration of mineral oil and ear irrigation are indicated for foreign body in the ear.
Question 21.
A patient has a live insect in the ear. Which action does the emergency nurse take first?
(a) Perform ear irrigation with lukewarm water.
(b) Gather equipment for manual extraction.
(c) Prepare for moderate sedation for the extraction.
(d) Administration of mineral oil in the ear canal.
Answer:
(d) Administration of mineral oil in the ear canal.
Rationale:
Removal of live insects should be attempted by drawing the insect toward the light using an otoscope or flashlight. If this fails, the insect should be killed using lidocaine or mineral oil before manual removal or flushing. Ear irrigation and manual extraction take place once the insect is dead. The procedure does not require sedation. Live insects in the ear are definitely an “emergency” to the patient! It is very unsettling for the patient!
Question 22.
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
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. Cfrganic ma¬terials 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 23.
A patient has profuse bleeding from the nose that has persisted despite application of firm pressure to the nostrils. Which of the following diagnostic evaluations is the priority test?
(a) Activated partial thromboplastin time (aPTT)
(b) Complete blood count (CBC) and prothrombin time (PT)
(c) International normalized ratio (INR)
(d) Hematocrit count and type and crossmatch
Answer:
(b) Complete blood count (CBC) and prothrombin time (PT)
Rationale:
The priority is to maintain a patent airway and ensure hemodynamic stability. Monitoring the amount of blood loss and preparing for blood replacement are inter-ventions that meet those priorities. Type and crossmatch are essential to prepare for blood volume replacement, if needed. Complete blood count (CBC), international normalized ratio (INR), partial thromboplastin time (aPPT), and prothrombin time (PT). are all important to determine clotting status and blood loss; however, the hematocrit and type and crossmatch are the priority tests.
Uncontrolled persistent epistaxis is indicative of a posterior bleed. Posterior bleeds originate in the posterior nasal or nasopharyngeal cavity and are typically arterial bleeds requiring nasal packing.
Question 24.
A patient is being discharged after treatment for epistaxis. Which of 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.”
Rationale:
Discharge instructions for patients with epi-staxis include avoiding anything that may contribute to continued bleeding or rebleed. Specific precautions include use of saline nasal spray, a humidifier, and taking warm showers to keep the nasal mucosa moist. They should also avoid hard blowing or sneezing, digital manipulation, and 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 25.
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
Rationale:
There is no definitive diagnostic test to con¬firm Bell’s palsy, and diagnosis is confirmed based on clinical presentation of the hallmark signs and symptoms. Facial radiology may confirm bone deformi¬ties 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 26.
Appropriate discharge instructions for the patient diagnosed with Bell’s palsy includes 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
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 27.
The emergency nurse is preparing a patient for discharge after incision and drainage of an auricular hematoma. Which of the following reflects accurate discharge teaching?
(a) Maintain the compression dressing until follow-up.
(b) Follow-up for reevaluation of the ear in 7 days.
(c) Antibiotics will not be indicated as there is no infection.
(d) Take nonsteroidal anti-inflammatory drugs to manage pain.
Answer:
(a) Maintain the compression dressing until follow-up.
Rationale:
Auricular, also referred to as perichondrial hematoma, is a complication from shearing forces to the anterior auricle resulting in hematoma formation between the skin and cartilage of the ear. It occurs from direct blunt force trauma to the ear and is a common injury seen in wrestling. A compression dressing is indicated to minimize the reformation of hematoma after incision and drainage procedure. The ear must be evaluated every 24 hours for several days. Antibiotics prophylaxis will be administered, and non-steroidal anti-inflammatory drugs should be avoided to minimize bleeding risk. Inadequate treatment or healing may result in a permanent deformity referred to as cauliflower ear.
Even though a pressure-type dressing is used, cover the ear with fluffed 4X4 gauzes to protect the cartilage in the ear. Pad the ear well.
Question 28.
A patient presents with high fever and the following signs and symptoms affecting the right ear: swelling, erythema and pain to the pinna, otorrhea, and decreased hearing. The emergency nurse prepares interventions for which of the following?
(a) Ruptured tympanic membrane
(b) Parotitis
(c) Otitis externa
(d) Mastoiditis
Answer:
(d) Mastoiditis
Rationale:
Acute mastoiditis is an inflammatory process secondary to bacterial infection of the mastoid air cells of the temporal bone. It may occur with an associated otitis media. Presentation includes fever, inflammation and erythema to the mastoid and auricle, otorrhea, hearing loss, and deep, localized pain behind the ear.
Ruptured tympanic membrane may result in impaired hearing, vertigo, and drainage (blood) from the ear. Parotitis is inflammation of the parotid gland and presents with unilateral swelling below the ear and jaw. Otitis externa is an infection and inflammation of the auditory canal and may present with itching of the ear canal and external ear, pain with movement of the ear and swelling of the ear canal. Fever is not a classic symptom of otitis externa.
Question 29.
Which of the following disorders does the emergency nurse NOT expect as a complication of mastoiditis?
(a) Bell’s palsy
(b) Tooth abscess
(c) Hearing loss
(d) Labyrinthitis
Answer:
(b) Tooth abscess
Rationale:
Tooth abscess is not an expected complication of mastoiditis. Complications include hearing loss, facial nerve palsy, osteomyelitis, labyrinthitis, meningitis, subdural empyema, and abscess formation to the bones and soft tissue near the mastoid.
Question 30.
A patient involved in a motor vehicle accident is being evaluated for a zygomatic fracture. Which of the following complaints indicates the presence of a zygomatic fracture?
(a) Altered sensation to the mandible
(b) Feeling of numbness to the ear
(c) Lack of feeling to the cheek
(d) Lack of movement to the chin
Answer:
(c) Lack of feeling to the cheek
Rationale:
The cheek, side of the nose, upper lip, teeth, and gums are all supplied by the infraorbital nerve as it exits through the zygoma, the main bone bridging the maxilla to the temporal bone. Paresthesia to those areas innervated by that nerve would be expected. The mandible and chin are supplied by the inferior alveolar nerve, which is a branch of the mandibular nerve. Ear numbness can be caused by sensory nerve-damage.
High-velocity motor vehicle accidents are a common mechanism of injury for comminuted fractures of the zygomatic process and often involve orbital rim fractures. A step-off deformity or flattened cheek is one of the manifestations that accompanies zygomatic fractures. Diplopia can also occur due to entrapment of one of the muscles that move the eyeball.
Question 31.
A patient has a suspected zygomatic fracture. The nurse prepares the patient for which of the following diagnostic tests that will confirm this diagnosis?
(a) Facial ultrasound
(b) Lateral facial radiograph
(c) Waters view radiograph
(d) Facial computed tomography (CT)
Answer:
(d) Facial computed tomography (CT)
Rationale:
Computed tomography (CT) is the preferred diagnostic imaging for zygomatic fracture. Waters view (occipitomental) radiographs, Caldwell view (occipitofrontal) radiographs, and ultrasound can be used to screen for (not diagnose) zygomatic fractures. Lateral facial radiograph is not indicated for zygomatic fracture.
Question 32.
Which of the following is the highest priority for ongoing monitoring of the patient with a nasal fracture?
(a) Bleeding is controlled
(b) Pain score decreased to 0 (zero)
(c) Extent of periorbital ecchymosis
(d) Development of fever
Answer:
(a) Bleeding is controlled
Rationale:
The highest priorities for ongoing evaluation of the patient with nasal fracture are patency of airway and maintenance of hemodynamic status. Monitoring for control of bleeding achieves the priority goal of hemodynamic stability. Control of pain is a priority and assessment should determine a pain score that is realistically tolerable for the patient.
Yet a pain score of 0 (zero) may not be realistic. Periorbital ecchymosis is expected and may get worse immediately after the trauma, with bruising dissipating days after the trauma. Septal hematoma leading to infection and necrosis is a complication of nasal fracture. The hematoma may need to be drained. The patient should also be placed on antibiotics and monitored for fever.
Question 33.
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) Blowout fracture
Answer:
(b) Sublingual hematoma
Rationale:
Mandibular fractures may manifest with sublingual bleeding or hematoma, trismus, malocclu¬sion, 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. Blowout 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.
Mandibular fractures can be an avenue for possible airway obstruction. The tongue can be displaced posteriorly due to the loss of bony support, and the growing sublingual hematoma can also cause a greater amount of posterior displacement.
Question 34.
A patient describes a fall resulting in hitting the chin on a table. He now complains of inability to open the mouth, malocclusion, and bleeding at the gum line. The emergency nurse suspects the patient has sustained which of the following fractures?
(a) Mandibular
(b) Zygomatic
(c) Basilar skull
(d) LeFort II
Answer:
(a) Mandibular
Rationale:
Inability to open the mouth due to spasms, also referred to as trismus, malocclusion, bleeding at the gum line, and sublingual hematoma are classic signs of mandibular fracture. Mandibular fractures occur with direct trauma to the jaw or chin. Zygomatic fractures occur following a blow to the zygoma and presents with altered sensation to the face. Basilar skull fractures and LeFort fractures occur with direct trauma to the front of the face.
Question 35.
Otorrhea and rhinor jhea are NOT typically associated with which of the following injuries?
(a) Basilar skull fracture
(b) LeFort III
(c) LeFort II fracture
(d) LeFort I fracture
Answer:
(d) LeFort I fracture
Rationale:
LeFort I, a transverse fracture across the maxilla, is not typically associated with cerebrospinal fluid (CSF) leaks. CSF leaks, as evidenced by otorrhea (drainage from the ear) and rhinorrhea (drainage from the nose), are seen in basilar skull fractures and LeFort II and LeFort III fractures.
The highest concern for LeFort fractures is airway obstruction. Especially with LeFort II and III, massive damage is done to the face and obstruction of the airway with broken teeth, blood, and clots, and emesis is an important aspect of care. Suctioning and airway control are of utmost importance! Also, patients with these types of fractures should be evaluated for head, neck, and multisystem trauma due to the significant force required.
Question 36.
The emergency nurse is caring for a patient who sustained significant blunt force trauma to the face. The nurse observes free-floating movement of the nose and infraorbital rim. Which of the following injuries is consistent with this presentation?
(a) LeFort I
(b) LeFort II
(c) Craniofacial disjunction
(d) Zygomatic fracture
Answer:
(b) LeFort II
Rationale:
LeFort II fracture is a pyramidal fracture across the bridge of the nose and involves the maxillary segment of the zygomatic, nasal and orbital bones. This can lead to the free-floating appearance of the nose and infraorbital rim. LeFort I fracture is a transverse fracture across the maxilla and the patient will present with malocclusion. LeFort III fracture is complete craniofacial disjunction and the patient will present with significant facial asymmetry and subcutaneous emphysema. Zygomatic fractures may have an associated orbital rim fracture, yet does not include a nasal fracture.
LeFort II and III fractures require early ocular examination as these fractures? will cause periorbital swelling and may delay the ability to examine the eyes.
Question 37.
A patient is being discharged after treatment for temporomandibular joint (TMJ) dislocation. The emergency nurse concludes that the patient needs additional instructions if he/she states which of the following?
(a) “This can reoccur if I open my mouth too wide or grind my teeth.”
(b) “I should take muscle relaxants for continued pain. ”
(c) “I will continue on a liquid diet until the follow-up visit.”
(d) “Soft foods for the next few days are the best option for eating.”
Answer:
(c) “I will continue on a liquid diet until the follow-up visit.”
Rationale:
Discharge instructions for the patient treated for temporal mandibular joint (TMJ) dislocation in¬clude a soft diet for 3 to 4 days, avoiding anything that may cause stress on the joint (that is, excessive yawn¬ing and teeth grinding), and taking muscle relaxants as needed. A liquid diet is not indicated.
TMJ dislocation is anterior and superior displacement of the jaw resulting in spasms that prevent the condyles from returning to normal position. It can occur unilaterally or bilaterally from something as simple as opening the mouth too wide.
Question 38.
A patient complains of unilateral ear pain, inability to close the mouth completely, neck pain, and a clicking sound every time he moves his jaw. The emergency nurse will prepare for interventions for which of the following?
(a) LeFort II fracture
(b) Nasal fracture
(c) Temporal mandibular joint dislocation
(d) Ruptured tympanic membrane
Answer:
(c) Temporal mandibular joint dislocation
Rationale:
Presentation consistent with temporoman¬dibular joint dislocation includes history of wide and prolonged mouth opening followed by malocclusion, trismus, headache, otalgia, neck pain, and a snap, click, or pop sensation with jaw movement. A LeFort II fracture is a pyramidal fracture across the bridge of the nose. LeFort II and nasal fractures are accompanied by epistaxis, nasal swelling, and asymmetry. Ruptured tympanic membrane presents with localized signs and symptoms of the ear such as decreased hearing, ear drainage, and otalgia.
Question 39.
The emergency nurse is preparing a patient for diagnostic evaluation of a suspected fractured larynx. Which of the following is most appropriate related to patient preparation for definitive testing?
(a) Place topical anesthetic spray at the bedside
(b) Secure intravenous access
(c) Check the patient’s creatinine (Cr)
(d) Prepare end-tidal C02 monitoring
Answer:
(a) Place topical anesthetic spray at the bedside
Rationale:
The most definitive diagnostic test for suspected laryngeal fracture is intranasal fiberoptic laryngoscopy. The procedure can be done at the bedside, and a topical anesthetic spray will be used to suppress the gag reflex during the procedure. Intravenous access may be warranted, yet contrast dye computed tomography (CT) may not be indicated unless there is a need to evaluate for associated neck injuries. Assessment of blood urea nitrogen (BUN) and creatinine is indicated before any scanning that requires contrast dye. While pulse oximetry is important for monitoring the patient at this time, ETC02 monitoring, indicated for moderate sedation, may not be needed.
Question 40.
A patient with a fractured larynx is hoarse, has neck pain, and the oxygen saturation is decreasing.
Which of the following interventions should the emergency nurse implement at this time?
(a) Insert a nasopharyngeal airway.
(b) Prepare for immediate cricothyrotomy.
(c) Have the patient suck on ice chips.
(d) Place the patient in a supine position.
Answer:
(b) Prepare for immediate cricothyrotomy.
Rationale:
A surgical airway is required for patients with a fractured larynx who are losing their airway. This patient will require oxygen due to the decreasing oxygen saturation, and the hoarseness and neck pain are indicators that a patent airway is not present. The patient should be NPO and the head of the bed should be elevated 30 to 45 degrees. Nothing should be placed in the nasal/oral-pharyngeal space due to potential stimulation of the gag reflex.
Question 41.
A college student presents with anxious appearance, drooling, muffled voice, high fever, and dyspnea. The emergency nurse prepares for which of the following?
(a) Intravenous access
(b) Immediate needle cricothyrotomy.
(c) Throat swab for group A Streptococci
(d) Assess immunization status
Answer:
(a) Intravenous access
Rationale:
Intravenous (IV) access is a priority intervention for blood specimen collection (complete blood count, blood culture), intravenous fluid, and antibiotic administration due to this patient exhibiting signs of acute epiglottitis. Epiglottitis is an infection and inflammation of the epiglottitis most frequently caused by Haemophilus influenzae type B (HiB) and group A streptococci.
Classic signs and symptoms of epiglottitis include extreme anxiety, drooling, dyspnea, sore throat, acute onset of high fever, tripod position, and stridor. The patient should be placed in a high-visibility bed near an emergency airway cart. Nothing should be placed in the mouth due to the potential laryngospasm.
Obtaining a complete history is important to determine the immunization status, yet IV ac¬cess is the priority. Needle cricothyrotomy is reserved for when If the patient with a fractured larynx requires supplemental oxygen, humidified oxygen is recommended because it is less irritating to the airway compared with oxygen that is not humidified.
The cardinal signs of epiglottitis include the three Ds—dyspnea, dysphagia, and drooling. Stridor is considered a late sign! No patient with drooling should ever be sent back to the waiting room!
Question 42.
A patient is being evaluated for epiglottitis. Which of the following diagnostic tests is NOT the priority?
(a) Complete blood count (CBC)
(b) Blood culture
(c) Lateral soft-tissue neck radiograph
(d) Complete metabolic panel (CMP)
Answer:
(d) Complete metabolic panel (CMP)
Rationale:
Diagnostic evaluation for the patient with sus-pected epiglottitis includes complete blood count (CBC), blood culture, and portable lateral soft-tissue radiograph. The CBC differential will show a shift to the left as an indication of bandemia consistent with a bacterial infection.
The neck radiograph will reveal a positive thumb print sign consistent with a swollen epiglottitis. Blood cultures are necessary as bacteremia is a potential with an epiglottitis diagnosis. Positive blood cultures are present in the adult patient approximately 25 % of the time. A complete metabolic panel (CMP) is not immediately indicated.
Epiglottitis used to<be a pediatric disease process. It is now seen maret in adults than in the pediatric population due to vaccinations against Haemophilus influenzae type B. In the adult patient, other organisms are often seen.
Question 43.
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
Rationale:
The most common history associated with si-nusitis 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 abscess, 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 44.
Treatment of the patient with sinusitis includes which of the following?
(a) Follow-up with Ear-Nose-Throat (ENT) provider
(b) Use of a cool compress over sinuses
(c) Nasal decongestant sprays for 10 days
(d) Humidifier in areas where patient spends most time
Answer:
(d) Humidifier in areas where patient spends most time
Rationale:
Patient education for the patient with sinusitis includes nasal decongestants for 3 to 5 days, elevation of head of bed, application of heat to the face, and use of a humidifier. Consultation to an ENT may occur if the patient has recurrent sinusitis or sinusitis that is not responding to treatment. Consultation from the emergency department is not indicated.
Question 45.
Diagnostic evaluation of the patient with acute uncomplicated sinusitis includes which of the following?
(a) Nasal swab for pultures
(b) Complete blood 'count (CBC)
(c) Palpation of the sinuses
(d) Magnetic resonance imaging (MR1)
Answer:
(c) Palpation of the sinuses
Rationale:
Acute uncomplicated sinusitis is a clinical diagnosis in which presenting signs and symptoms are coupled with inspection and palpation techniques of the sinuses. Nasal swabs are rarely performed in the emergency setting, yet may be indicated when chronic recurrent sinusitis exists. A complete blood count (CBC) may be within normal range, unless the infection has become systemic. Magnetic resonance imaging (MRI) is valuable for evaluation of soft tissue of the sinuses, yet it is of little value in the diagnosis of sinusitis.
Question 46.
Which of the following statements indicates that a patient understood discharge instructions for sinusitis?
(a) “I will be sure to drink more water while I have this infection.”
(b) “I will be sure to use the antibiotics until the symptoms are gone.”
(c) “I can use the nose drops for 2 weeks, until my follow-up appointment.”
(d) “Cool compresses should help with the stuffiness and headache.”
Answer:
(a) “I will be sure to drink more water while I have this infection.”
Rationale:
The patient with sinusitis should increase their fluid intake to facilitate liquification of nasal secretions. The full course of antibiotics, if prescribed, should be completed. Antibiotics should not be taken only until symptoms are gone. Typically, phenylephrine nasal spray may be used as a decongestant for short periods of time, maximum of 3 days due to the potential for rebound congestion. Warm compresses should be used to relieve nasal pressure and stuffiness by loosening secretions, which will then result in decreased sinus pain.
Question 47.
A patient with poor dentition presents with high fever, agitation, malodorous breath, edematous tongue, and inability to completely close the mouth. On assessment, the ED nurse notes firm swelling below the mandible extending to the lower neck. The emergency nurse prepares for diagnostic testing for which of the following?
(a) Ludwig’s angina
(b) Vincent’s angina
(c) Epiglottitis
(d) Dental abscess
Answer:
(a) Ludwig’s angina
Rationale:
Ludwig’s angina is a bacterial infection of the submandibular space. Classic presentation, includes high fever, agitation, malodorous breath, edematous tongue, inability to completely close the mouth, dyspnea, drooling, upward and backward displacement of the tongue, trismus, and marked swelling below the mandible extending to the lower neck. History often includes poor dental hygiene, including dental abscess and other comorbidities such as immunosuppressive disorders.
Vincent’s angina, also referred to as trench mouth or acute ulcerative gingivitis, results in mouth and gum bleeding and pain. Epiglottitis is an infection of the epiglottis, resulting in dyspnea, dysphagia, and drooling. Of the named disorders, only Ludwig’s angina results in swelling to the mandible, neck, and mediastinum.
Question 48.
The emergency nurse recognizes which of the following pathophysiologic alterations occurring with Ludwig’s angina takes the highest priority?
(a) Tripod position and limited range of motion to the jaw
(b) Invasion of B-hemolytic streptococcus bacteria into the submandibular region of the neck
(c) Elevation and posterior displacement of the tongue
(d) Temperature: 102° F (38.9° C); pulse: 106 beats/ minute; respirations: 24 breaths/minute
Answer:
(c) Elevation and posterior displacement of the tongue
Rationale:
Progressive infection of the submandibular region, neck, and mediastinum’results in upward and posterior displacement of the tongue. Severe upper airway obstruction can occur secondary to tongue displacement and should be considered the highest priority when planning care. The care team should be prepared for advanced airway management with nasal or oral airway insertion, laryngeal mask airway, or surgical airway (tracheostomy).
Abnormal vital signs are consistent with infection of B-hemolytic streptococci bacteria. Tripod positioning is a compensatory position assumed by the patient to facilitate breathing. Trismus (inability to open/close the mouth due to spasms) occurs causing lim¬ited range of motion of the jaw and the tripod positioning helps to overcome this as well.
Question 49.
A patient has muffled voice, difficulty opening the mouth, and significant firm swelling with crepitus below the jaw extending to the neck. Vital signs are as follows:
Blood pressure—118/64 mm Hg Pulse—102 beats/minute Respirations—24 breaths/minute Temperature—101.5° F (38.6° C)
Pulse oximetry—94 % on room air.
The patient is placed on humidified oxygen via face mask. Which of the following is the next priority intervention?
(a) Prepare for emergency cricothyrotomy
(b) Radiology for computed tomography (CT)
(c) Administer oral antipyretics
(d) Administer intravenous antibiotics
Answer:
(d) Administer intravenous antibiotics
Rationale:
Airway patency and adequate oxygenation are the highest priorities in a patient with Ludwig’s angina. The patient is hble to vocalize, and humidified oxygen is being administered. The next priority intervention is securing intravenous access for specimen collection and administration of fluids and antibiotics. Diagnostic testing is indicated to confirm the infection and determine the degree of airway compromise; however, initiation of treatment should not be delayed and should be based on the clinical diagnosis. Nothing should be administered orally. Emergency tracheostomy would be a preferred advanced airway over cricothyrotomy due to severe airway swelling.
Question 50.
A patient with a history of poor dental hygiene and recent completion of chemotherapy presents with fever, mouth pain, swelling and bleeding to the gums, and malodorous breath. Which of the following actions would NOT be appropriate?
(a) Initiate dental consult
(b) Suction the oropharynx
(c) Intravenous access
(d) Antibiotic administration
Answer:
(b) Suction the oropharynx
Rationale:
Airway compromise is not an expected finding and there is no indication that the airway is not patent; Ludwig’s angina is an airway emergency. therefore, suctioning is not indicated. Vincent’s angina, also referred to as acute necrotizing ulcerative gingivitis or trench mouth, is a bacterial infection of the gums. History typically includes immunosuppression, malnourishment, and poor dental hygiene. Classic presentation of Vincent’s angina includes bleeding, painful and swollen gums, fever, halitosis, and gray pseudomembranous ulcers on the pharynx. Intravenous access should be obtained for specimen collection, intravenous fluids, and antibiotic administration. The patient should be seen by a dentist for definitive management.
Another piece of information about chemotherapy patients remember that these patients should never go back to the waiting room! The waiting room is full of contagious organisms. Any patient who is considered to be neutropenic (low white blood cell count) should not be around others with possible contagious diseases. It does not matter what the patient is presenting with they cannot go back to the waiting room!
Question 51.
A patient has fever, gingival pain, bleeding gums, and foul breath. The patient is suspected of having trench mouth. Which of the following is another term for this disorder?
(a) Ludwig’s angina
(b) Vincent’s angina
(c) Pericoronitis
(d) Dental abscess
Answer:
(b) Vincent’s angina
Rationale:
Vincent’s angina, also referred to as acute necrotizing ulcerative gingivitis or trench mouth, is a bacterial infection of the gums. Classic presentation of Vincent’s angina includes bleeding, painful and swol¬len gums, fever, halitosis, and gray pseudomembranous ulcers on the pharynx. Ludwig’s angina is bacterial invasion of the submandibular structures. Pericoronitis is inflammation of the gingival tissue around the crown of an erupting or impacted tooth. Dental abscess is the localized accumulation of pus in various regions of the tooth and gum. Dental abscess can lead to complicatiQns of Vincent’s or Ludwig’s angina.
Question 52.
Which of the following statements made by a patient diagnosed with Vincent’s angina indicates the need for further instruction?
(a) “I will eat a well-balanced diet.”
(b) “I know to take all the antibiotics as directed.”
(c) “I should rinse my mouth with antiseptic mouthwash.”
(d) “I will brush my teeth with a hard-bristle toothbrush.”
Answer:
(d) “I will brush my teeth with a hard-bristle toothbrush.”
Rationale:
Vincent’s angina is a bacterial infection of the gums, resulting in bleeding and painful and swollen gums. Once brushing can be tolerated, a soft-bristle toothbrush should be used or the patient can gently wipe the gums. The patient should be instructed to eat nutritious food, take antibiotics as prescribed, and rinse the mouth with an antiseptic mouthwash in the acute phase of the infection.
Question 53.
The emergency nurse understands that the condition in which bacteria or viruses cause inflammation of the cochlea and other structures of the inner ear is referred to as which of the following?
(a) Vertigo
(b) Sinusitis
(c) Meniere’s
(d) Labyrinthitis
Answer:
(d) Labyrinthitis
Rationale:
Labyrinthitis is an inflammatory process of the structure of the inner ear, the labyrinth. Meniere’s disease is a disorder affecting the inner ear and is thought to be due to increased fluid and pressure in the endolym¬phatic system. Sinusitis is an inflammatory process of the
sinuses secondary to infection. Vertigo is the feeling of spinning and is associated as a manifestation with both labyrinthitis and Meniere’s disease.
Question 54.
The emergency niirse prepares to administer all of the following to the patient diagnosed with labyrinthitis EXCEPT:
(a) Promethazine (Phenergan).
(b) Meclizine (Antivert).
(c) Pseudoephedrine (Sudafed).
(d) Lorazepam (Ativan).
Answer:
(c) Pseudoephedrine (Sudafed).
Rationale:
Pseudoephedrine (Sudafed) is a deconges¬tant that is not typically indicated for the treatment of labyrinthitis as nasal stuffiness is not part of the typical presentation. Meclizine (Antivert) is an antihistamine used to treat vertigo one of the main symptoms of labyrinthitis. Promethazine (Phenergan) is an antiemetic that has sedative effects and may help with symptoms of nausea and vertigo. Lorazepam (Ativan) is a benzodiazepine, which may assist with resolving vertigo and diminish general anxi¬ety experienced due to all symptoms.
Question 55.
Which of the following does the emergency nurse inquire about in the history of a patient with labyrinthitis?
(a) Otitis media
(b) Sinusitis
(c) Epistaxis
(d) Mastoiditis
Answer:
(a) Otitis media
Rationale:
Preexisting disorders for labyrinthitis in¬clude bacterial ear infections, recent viral infections, barotrauma, migraine headaches, Meniere’s syndrome, meningitis, arteriosclerosis, and systemic autoimmune disorders such as systemic lupus erythematous. Sinus¬itis and mastoiditis, although may be concurring with labyrinthitis, are not typically preexisting conditions. Epi- staxis is not associated with labyrinthitis.
Question 56.
The emergency nurse is preparing for diagnostic evaluation of the patient with labyrinthitis. Which of the following is expected to assist with confirmation of this disorder?
(a) Caloric testing will reveal increased response on the affected side.
(b) Audiogram will reveal hypersensitivity to low- and high-pitch sounds.
(c) Caloric testing will reveal decreased or absent response on affected side.
(d) Magnetic resonance imaging (MRI) will reveal a mass as the cause of symptoms.
Answer:
(c) Caloric testing will reveal decreased or absent response on affected side.
Rationale:
Caloric reflex testing, a test of the vestibulo-ocular reflex, is performed by instilling cool water onto the tympanic membrane and evaluating for nystagmus. A person with labyrinthitis would be expected to have a decreased or absent response on the affected side. An audiogram will reveal some degree of conductive or sensorineural hearing loss.
The patient may be sensitive to loud sounds, yet audiography is not needed to determine this finding. Magnetic resonance imaging (MRI) may be used to rule out the presence of a mass as seen in other conditions that may cause similar symptoms. MRI may also be used to confirm labyrinthitis as the cochlea, vestibule, and semicircular canals will show changes post contrast but would be done at a later time.
Before caloric testing, one must visually inspect the tympanic membrane to ensure it is intact. A ruptured tympanic membrane is a contraindication of testing.
Question 57.
A 55-year-old patient reports episodes of the sensation that the room is rotating, inability to walk without falling, nausea, and a roaring sensation in the ear. The emergency nurse prepares for treatment of which of the following?
(a) Mastoiditis
(b) Meniere’s disease
(c) Sinusitis
(d) Otitis media
Answer:
(b) Meniere’s disease
Rationale:
Meniere’s disease, also referred to as en-dolymphatic hydrops, is thought to be caused by increased fluid and pressure in the inner ear resulting in destruction of the vestibular and cochlear apparatus. It occurs most frequently in those between 50 and 60 years of age. The classic presentation includes episodic rotational vertigo, ataxic gait, tinnitus (roaring or ringing in the ears), nausea, diaphoresis, and sensorineural hearing loss. The exact cause is unknown, yet it may be associated with trauma, infection, or degeneration of the inner ear. Otitis media would present with ear pain and fever. Mastoiditis would have manifestations of pain in the mastoid area associated with swelling, fever, and headache. Sinusitis symptoms would include fever, pain and tenderness in the sinus areas, and drainage.
Question 58.
Which of the following does the emergency nurse expect to be in the treatment plan for a patient with Meniere’s disease yet not for labyrinthitis?
(a) Administration of antiemetic medication
(b) Instructions to change positions slowly
(c) Instructions to avoid operation of heavy machinery
(d) Administration of diuretic medication
Answer:
(d) Administration of diuretic medication
Rationale:
Diuretics and low sodium diet are part of the treatment plan for the patient with Meniere’s disease to decrease the fluid and pressure build up in the en-dolymphatic system. Labyrinthitis is due to viral or bacterial infections, leading to inflammation of the labyrinth. Nausea and vertigo are experienced in both disorders. Hence, the need for antiemetics and instructions to manage vertigo and maintain safety.
Question 59.
Which of the following pharmaceutical treatments does the emergency nurse prepare as a priority for the patient with Meniere’s disease?
(a) Erythromycin (E-Mycin)
(b) Phenylephrine
(c) Meclizine (Antivert)
(d) Ibuprofen (Advil)
Answer:
(c) Meclizine (Antivert)
Rationale:
Meclizine (Antivert) is an antihistamine used to treat vertigo a major symptom of Meniere’s disease. Meniere’s disease is not caused by bacterial infection; therefore, erythromycin, a macrolide antibiotic, will not be indicated. Phenylephrine is used as a nasal decongestant for sinusitis and other disorders affecting the nasal passages, such as rhinitis and is not indicated in the treatment of Meniere’s disease. Although an analgesic such as ibuprofen may be taken for discomfort (headache and feeling of fullness in the ear) experienced from Meniere’s disease, treating the debilitating symptoms of vertigo and nausea are higher priorities.
Question 60.
Which of the following patients is at highest risk for complete airway compromise?
(a) Retropharyngeal abscess
(b) Trigeminal neuralgia
(c) Vincent’s angina
(d) Bell’s palsy
Answer:
(a) Retropharyngeal abscess
Rationale:
A retropharyngeal abscess is an infection in the deep space of the neck, posterior to the pharynx, nasopharynx, and oropharynx. An infection can result in an abscess large enough to cause obstruction to the airway. Trigeminal neuralgia is a repetitive firing of the trigeminal nerve and results in painful spasms to the face. Vincent’s angina is necrotizing gingivitis and results in bleeding, painful gums. Bell’s palsy is paralysis of the facial nerve and results in unilateral palsy of the face.
Question 61.
The emergency nurse is assessing a child who has torticollis, high fever, and swollen lymph nodes to the neck. The emergency nurse suspects this child has which of the following diagnoses?
(a) Epiglottitis
(b) Laryngitis
(c) Retropharyngeal abscess
(d) Streptococcal pharyngitis
Answer:
(c) Retropharyngeal abscess
Rationale:
Retropharyngeal abscess results in significant neck stiffness and pain, fever, sore throat, cough, drooling, and cervical lymphadenopathy. The severe neck stiffness and pain can result in the infant or child tilting the head to one side with the chin tilted in the opposite direction. Epiglottitis more commonly affects adolescents and young adults and presents with high fever, dyspnea, dysphagia, and drooling. Tonsillitis presents with fever, sore throat, referred pain to the ear, and exudate on the tonsils. Laryngitis presents with hoarseness and difficulty swallowing. Torticollis and cervical lymphadenopathy are not classic signs of epiglottitis, tonsillitis, or laryngitis.
Question 62.
Which of the following diagnostic tests is the highest priority for the patient with retropharyngeal abscess?
(a) Chest radiograph
(b) Lateral neck radiograph
(c) Blood specimen for white blood count
(d) Computed tomography (CT) of the neck
Answer:
(b) Lateral neck radiograph
Rationale:
Widening of the retropharyngeal soft tissues, which can be easily seen on lateral neck radiograph and is consistent with retropharyngeal abscess in a large percentage of cases is the priority diagnostic test. A small percentage of patients with retropharyngeal abscess will have a normal white blood cell count; therefore, this test cannot be used to rule out the diagnosis.
A chest radiograph to assess for concurrent infection or complications such as mediastinitis and pneumonia should be done, yet are not exclusively diagnostic for retropharyngeal abscess. Computed tomography (CT) may be indicated after a lateral neck radiograph to determine the extent of the infection and assist with treatment options.
Question 63.
The emergency nurse examines a patient with a complaint of sore throat and notes uvular deviation, muffled voice, and foul odor to breath. Which of the following diagnoses is the highest probability with these manifestations?
(a) Peritonsillar abscess
(b) Retropharyngeal abscess
(c) Tonsillitis
(d) Pharyngitis
Answer:
(a) Peritonsillar abscess
Rationale:
Peritonsillar abscess results from infection to the tonsillar capsule and results in uvular deviation, “hot potato” (muffled) voice, drooling, dysphagia, and halitosis. Retropharyngeal abscess, tonsillitis, and pharyngitis are all infectious processes that cause sore throat, yet none cause uvular deviation and the classic “hot potato” quality to the voice.
Question 64.
A patient is being evaluated for a peritonsillar abscess. For which of the following should the emergency nurse prepare?
(a) Computed tomography (CT)
(b) Neck radiograph
(c) Throat swab
(d) Incision and drainage
Answer:
(d) Incision and drainage
Rationale:
Incision and drainage of the abscess is indicated so that cultures can be obtained and to provide immedi¬ate relief of symptoms by removing pus and decreasing the size of the abscess. Computed tomography may be indicated if direct visualization of the area is not possible. Neck radiograph and throat swab do not provide information about the type of purulent drainage in the abscess.
Question 65.
A patient describes sudden onset of unilateral face pain after chewing a hard candy. The pain is described as an electric shock. The emergency nurse proceeds to evaluate the patient for:
(a) Fractured tooth.
(b) Bell’s palsy.
(c) Ruptured tympanic membrane.
(d) Trigeminal neuralgia.
Answer:
(d) Trigeminal neuralgia.
Rationale:
Trigeminal neuralgia is repetitive firing of the trigeminal nerve resulting in painful spasms to the face. The pain is usually unilateral and is described as an excruciating, stabbing, electric shock. It is triggered by chewing, brushing teeth, or touching the face. A fractured tooth may result from chewing on something hard and results in sensitivity to air or temperature variations. Patients with Bell’s palsy may complain of pain near the ear, yet the quality is not described as electric shock. A ruptured tympanic membrane can result in significant ear pain, especially if it occurs secondary to trauma, yet the quality is not described as electric shock.
Question 66.
The emergency nurse understands that trigeminal neuralgia is a disorderjthat affects which of the following cranial nerves?
(a) Seventh (Facial)
(b) Fifth (Trigeminal)
(c) Second (Optic)
(d) Third (Oculomotor)
Answer:
(b) Fifth (Trigeminal)
Rationale:
THgeminal neuralgia is a disorder that affects the fifth (THgeminal) cranial nerve, resulting in repeti¬tive firing of the nerve that then cause painful spasms to the face. The seventh (Facial) cranial nerve is affected in Bell’s palsy. The second (Optic) cranial nerve is responsible for the sensory function of visual acuity. The third (Oculo¬motor) cranial nerve is responsible for the motor function of the eye, including pupil constriction and dilation.
Just as a follow-up on the cranial nerves remember that when assessing extraocular eye movements', EOMs, the nerves involved are three (Oculomotor), four (Trochlear), six (Abducens). This is often on the test! On the test, the cranial nerves are usually listed by number and by name. So for this question, it made it awfully easy, right?
Question 67.
Which of the following principles does the emergency nurse use to determine triage acuity for a patient with an avulsed tooth?
(a) Tooth that is affected
(b) Formation of clots
(c) Time of injury
(d) Solution tooth is in
Answer:
(c) Time of injury
Rationale:
An avulsed tooth is an emergency because teeth reimplanted within 30 minutes have a better chance of survival. The specific tooth that is avulsed does not determine triage acuity. Primary teeth are not reimplanted because it can result in injury to the per¬manent tooth. Bleeding that cannot be controlled with pressure, such as biting down on a gauze, should be considered for up-triage. Avulsed teeth should be placed in milk or saline solution. Caution should be taken to not handle the root of the tooth.
Question 68.
A parent reports her 18-month-old child had sudden onset of a persistent cough. The child is afebrile and has mild stridor on assessment. The emergency nurse prepares for further evaluation of which of the following?
(a) Upper airway obstruction
(b) Peritonsillar abscess
(c) Nasal foreign body
(d) Ludwig’s angina
Answer:
(a) Upper airway obstruction
Rationale:
Most foreign body aspirations occur in children younger than 3 years of age. Any young pediat¬ric patient with an acute onset of persistent cough, wheeze, or stridor should be evaluated for foreign body in the airway. Foreign body aspirations usually go into the right bronchus. It is straighter, wider, and has greater airflow. Peritonsillar abscess will result in stridor, yet the patient will be febrile. A pediatric patient with a nasal foreign body will likely have pain, swelling, and a foul odor or drainage from the nose. Ludwig’s angina is a deep infection to the soft tissue of the neck resulting in high fever and dyspnea, yet not a persistent cough.
Question 69.
The emergency nurse is providing instructions to a patient with parotitis. Which of the following is the rationale for instructing the patient to gently massage the parotid gland?
(a) Help to dry up secretions from the gland.
(b) Relieve pain associated with infection of the gland.
(c) Facilitate drainage of secretions from the gland.
(d) Minimize loss of muscle function around the gland.
Answer:
(c) Facilitate drainage of secretions from the gland.
Rationale:
Parotitis is inflammation of the parotid gland, the largest salivary gland. Inflammation can occur secondary to viral or bacterial invasion, or calculi formation. Massaging the gland helps to promote drainage. The patient should also be instructed to increase fluid intake and use agents such as lemon drops to increase saliva production. Massaging would not dry
secretions, relieve the pain, or affectmuscle function.
Question 70.
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
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 71.
The emergency nurse observes purulent drainage from a patient’s ear. The patient complains of decreased hearing and a sensation of the room spinning. The emergency nurse prepares interventions for which of the following?
(a) Otitis externa
(b) Suppurative otitis media
(c) Labyrinthitis
(d) Ruptured tympanic membrane
Answer:
(b) Suppurative otitis media
Rationale:
Ruptured tympanic membrane is a complication of otitis media as fluid accumulates and pressure builds in the inner ear. Bloody or purulent discharge, decreased hearing, tinnitus, and vertigo are classic presentations of ruptured tympanic membrane. It is not common for tinnitus and vertigo to occur with otitis media or otitis externa. Purulent drainage is not common in labyrinthitis.
Question 72.
A patient is being evaluated for a ruptured tympanic membrane. Which of the following preexisting conditions is NOT related to the diagnosis?
(a) Head trauma with blood behind the tympanic membrane .
(b) Concurrent sinusitis and frequent airline travel
(c) Swimmer’s ear
(d) Otitis media
Answer:
(c) Swimmer’s ear
Rationale:
Otitis externa, referred to as swimmer’s ear, results in closure of the ear canal, yet does not typically result in ruptured tympanic membrane. The most common cause of ruptured tympanic membrane is infection. Trauma to the head, face, or ear, resulting in hemotympanum and barotrauma secondary to change in altitude, can result in ruptured tympanic membrane.
Question 73.
A patient has extreme itching to the ear and swollen pre and postauricular lymph nodes. The emergency nurse suspects the patient has:
(a) Otitis externa.
(b) Otitis media.
(c) Mastoiditis.
(d) Meniere’s disease.
Answer:
(a) Otitis externa.
Rationale:
Otitis externa, referred to as swimmer’s ear, is an inflammatory process of the external ear canal and the auricle. Classic presentation includes pruritis, erythema, swelling, pain around the auricle, and swollen lymph nodes. The swelling can be severe and result in complete closure of the ear canal. Otitis media results in ear pain, pulling or tugging on the ear, and a sensation of fullness to the ear. Mastoiditis results in pain, erythema, and swelling to the mastoid bone. Meniere’s disease is characterized by vertigo, tinnitus, nausea, and vomiting. .
Question 74.
A parent describes the infant as grabbing at the ear, history of fever, irritability, and decreased appetite. The emergency nurse prepares interventions for which of the following?
(a) Otitis externa
(b) Otitis media
(c) Foreign body in the ear
(d) Ruptured tympanic membrane
Answer:
(b) Otitis media
Rationale:
Otitis media is a common childhood infection, and classic presentation in infants includes pulling, grabbing or placing their finger in the ear, fever, irritability, and decreased appetite. Older children or adults may complain of the sensation of fullness in the ear and decreased hearing. Otitis externa is characterized by swelling and intense itching of the external auditory canal. Ruptured tympanic membrane is characterized by drainage from the ear, tinnitus, transient vertigo, and decreased hearing. Foreign body in the ear is characterized by sensation of something in the ear and possible drainage from the ear, yet fever is not to be expected.
Question 75.
The emergency nurse suspects a patient has otitis media. Which of the following would be an appropriate diagnostic evaluation tool?
(a) Culture of the ear canal
(b) Blood specimen
(c) Whisper voice test
(d) Otoscopic examination
Answer:
(b) Blood specimen
Rationale:
Otitis media is an infection of the middle ear and is diagnosed with otoscopic examination to provide direct visualization of the tympanic membrane (TM). The TM may appear yellow, white, or have erythemic discoloration, be bulging or retracted, or have purulent discharge, or a visible fluid line. The infection is local; therefore, blood specimen collectiofl to look for systemic infection is not indicated. Culture of the ear canal may be in-dicated in otitis externa. The whisper voice test may be done to test for gross hearing, yet is not diagnostic for otitis media.