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Medical and Communicable Diseases CEN Practice Questions - CEN Questions on Medical and Communicable Diseases.
Question 1.
Which of the following is the treatment of choice for anaphylaxis?
(a) Pseudoephedrine
(b) Epinephrine
(c) Antihistamine
(d) Corticosteroid
Answer:
(b) Epinephrine
Rationale:
Epinephrine is the treatment of choice in all cases of anaphylaxis. By stimulating vascular alpha- adrenergic receptors, epinephrine causes vasoconstriction, thereby increasing vascular resistance and blood pressure. Through its beta-receptor-stimulating actions, epinephrine increases the force and rate of myocardial contraction and relaxes bronchial smooth muscle, resulting in bronchodilation. Pseudoephedrine is an alpha- and beta-adrenergic agonist that may also en-hance release of norepinephrine.
It has been used in the treatment of several disorders, including asthma, heart failure, rhinitis, and urinary incontinence, and for its cen-tral nervous system stimlilatory effects in the treatment of narcolepsy and depression. Antihistamines work by physically blocking the H,-receptors, stopping histamine from reaching its target. This decreases the body’s reaction to allergens and therefore helps to reduce the troublesome symptoms associated with allergies. Corticosteroids are used mostly for their strong anti-inflammatory effects and in conditions that are related to the immune system function.
Remember that diphenhydramine (Benadryl) and corticosteroids are used in the treatment of anaphy-laxis, but epinephrine (Adrenaline) is the first-line drug because of its immediate action.
Question 2.
Which of the following body systems is most involved in anaphylaxis?
(a) Gastrointestinal system
(b) Respiratory system
(c) Integumentary system
(d) Neurologic system
Answer:
(c) Integumentary system
Rationale:
Anaphylactic reactions almost always involve skin manifestations. Pruritus (itching) and small or localized urticaria (hives) are often present with a minor allergic reaction. In anaphylaxis, widespread urticaria and itching may occur, along with angioedema. Crampy abdominal pain, nausea, vomiting, or diarrhea rarely occurs, unless the reaction is triggered by a food allergy. Rhinorrhea, nasal congestion, hoarseness, throat tightness, cough, wheezing, and shortness of breath are respiratory symptoms found in about 60% of allergic/anaphylactic reactions. Neurologic symptoms (dizziness, blurred vision, headache, and seizure) are very rare and are secondary to the hypotension that occurs with anaphylaxis.
Question 3.
Which of the following is a clinical indication of systemic inflammatory response syndrome (SIRS)?
(a) Bradycardia
(b) Slow, shallow respirations
(c) Elevated white blood cell count
(d) Hypertension
Answer:
(c) Elevated white blood cell count
Rationale:
The signs of SIRS include tachycardia (elevated heart rate), tachypnea (elevated respiratory rate), an elevated temperature (or hypothermia), and an elevated white blood cell count and/or greater than 10% bands or immature neutrophils, also termed bandemia. Hypertension is not considered a sign of SIRS. Hypotension commonly occurs in sepsis, but is not a SIRS criterion.
The SIRS response is not only involved in sepsis, but also occurs with both infectious and noninfectious processes. SIRS with infection is sepsis.
Question 4.
Goal-directed initial resuscitation measures for septic shock include which of the following?
(a) Treating a state of hypoperfusion
(b) Decreasing systemic vascular resistance (SVR)
(c) Administrating epinephrine subcutaneously
(d) Utilizing intravenous diuretic therapy
Answer:
(a) Treating a state of hypoperfusion
Rationale:
Because septic shock is associated with a high mortality rate due to a state of severe hypoperfusion, early goal-directed resuscitation measures include treating the state of hypoperfusion. This includes fluid boluses, increasing the systemic vascular resistance (SVR) with vasopressor agents, and/or administering packed red blood cells (PRBCs) if needed.
These measures will decrease the risk of end-organ damage of ten seen in cases of septic shock. Systemic vascular resistance is lowered in septic shock and treatment is aimed at increasing resistance. International guidelines recommend dopamine or norepinephrine as first-line vasopressor agents in septic shock, whereas epinephrine and vasopressin are considered as second-line agents. The effect of vasopressors will improve renal output; thus, there is no indication for diuretic therapy.
Question 5.
Sickle cell crisis is associated with a number of precipitants. Which of the following is NOT one of these precipitants?
(a) Cold ambient temperature
(b) Infection
(c) Metabolic or respiratory alkalosis
(d) High altitude
Answer:
(c) Metabolic or respiratory alkalosis
Rationale:
A state of acidosis, not alkalosis, can precipitate a sickle cell crisis. Acidosis results in a shift to the right on the oxyhemoglobin dissociation curve (Bohr effect), causing hemoglobin to desaturate (release oxygen) more readily. Cold ambient temperature, infection, and high altitude are well-documentecl triggers of sickle cell crisis, and patients with this disease are instructed to take appropriate actions to avoid exposure to these triggers.
Question 6.
A nonresponsive, 64-year-old patient has the following findings in the emergency department: blood glucose 340 mg/dL, serum osmolality 320 mOsm/kg, and pH 7.2. The patient is taking deep, gasping respirations. The emergency nurse should suspect which of the following disease processes?
(a) Hyperthyroid crisis (Storm)
(b) Hyperosmolar hyperglycemic syndrome (HHS)
(c) Syndrome of inappropriate antidiuretic hormone (SIADH)
(d) Diabetic ketoacidosis (DKA)
Answer:
(d) Diabetic ketoacidosis (DKA)
Rationale:
Most hyperglycemic emergencies are due to diabetic ketoacidosis (DKA). A decrease in available insulin increases the blood glucose level because it cannot be transported into cells. To meet the body’s energy needs, the liver metabolizes fatty acids, which break down into ketone bodies. Dehydration, electrolyte losses, acidosis, and ketonuria ensue. Kussmaul respirations (deep, rapid breathing) are a compensatory mechanism to buffer the acidosis by reducing serum carbon dioxide levels. Patients with thyroid storm will appear in a hyperdynamic state, with elevated heart rate, blood pressure, and temperature.
Metabolic changes are not common. Hyperosmolar hyperglycemic syndrome (HHS) is characterized by blood glucose levels greater than 600 mg/dL and an absence of acidosis. Syndrome of inappropriate antidiuretic syndrome, due to oversecretion of the antidiuretic hormone, is characterized by decreased urinary output and sodium levels, lethargy, and confusion.
Remember that the respiratory system is in control of the acid parameter of acid-base balance. When a situation of metabolic acidosis occurs, the body responds by blowing off the carbon dioxide, thus at-tempting to reduce the acid in the body.
Question 7.
An 11-month-old child is brought to the emergency department by his parents. His parents tell the emergency nurse he has been coughing and has had a runny nose for 1 day. He has a red rash on his face, a rectal temperature of 102.5° F (39.2° C), and bluish-white spots on his buccal mucosa. Which of the following conditions are these symptoms associated with?
(a) Mumps
(b) Measles (Rubeola)
(c) Allergic reaction
(d) Varicella (chicken pox)
Answer:
(b) Measles (Rubeola)
Rationale:
The CDC immunization schedule for children is a first dose at age 12 to 15 months, followed by a second dose between ages 4 and 6 years, before the child enters school. An 11-month-old would not have had the vaccine yet. Koplik spots, small, red specks with a bluish-white center on the buccal mucosa, are a diag-nostic lesion of measles. They appear approximately 2 days before the rash and disappear within 48 hours after the rash.
There is a difference between rubella (also known as 3-day measles) and rubeola (commonly known as measles). Mumps cause glandular enlargement of the parotid and salivary glands. There is no rash associated with mumps. In postpuberty males, the testes may be involved, producing orchitis and a risk of infertility. An allergic reaction may produce urticaria, hives, and a disseminated rash. The characteristic symptom of varicella is a vesicular rash that begins on the trunk and becomes generalized.
Question 8.
When discharging a patient with sickle cell disease which of the following statements indicates the patient understands how to avoid precipitating a sickle cell crisis?
(a) “I will self-manage flu-like symptoms for 48 hours before calling my physician.”
(b) “I can continue to participate in cold weather sporting events. ”
(c) “When I am angry,’I will keep my feelings to myself.”
(d) “I will drink at least 64 ounces of water every day.”
Answer:
(d) “I will drink at least 64 ounces of water every day.”
Rationale:
Dehydration can precipitate a vaso-occlusive crisis in the capillary circulation. Microvascular occlusion leads to tissue ischemia and severe pain. Patients should ensure they have an adequate intake of fluids every day. Infection is a precipitant of sickle cell crisis and patients should seek immediate medical attention at the first signs of malaise. Exposure to cold temperatures results in vasoconstriction of blood vessels in the skin, hands, feet, nose, and ears.
This response is greatly exaggerated in the presence of sickle cell disease. Stressful events trigger the release of vasoactive hormones, which narrow blood vessels. This can lead to a vaso-occlusive crisis. Patients with sickle cell disease need strong coping mechanisms and communication skills to address stress.
Question 9.
A patient comes to the emergency department complaining of a nosebleed that began 2 hours before her arrival, and has not subsided, despite direct pressure. She has generalized ecchymosis, and states she has a history of idiopathic thrombocytopenia (ITP). Replacement therapy is indicated based on the diagnostic workup. Which of the following is the appropriate treatment?
(a) Desmopressin (DDAVP)
(b) IVIg (intravenous immunoglobulin)
(c) Thrombin injection
(d) Factor VIII
Answer:
(b) IVIg (intravenous immunoglobulin)
Rationale:
In the patient with known idiopathic thrombocytopenia (ITP), an intravenous infusion of immunoglobulin (IVIg) is a first-line intervention, because it causes a rapid rise in the platelet levels. Platelet transfusion can also be considered if the count is less than 50,000 and in the presence of severe hemorrhage. Desmopressin is a synthetic version of vasopressin, which increases the levels of factor VIIIc in the treatment of mild-to-moderate hemophilia. Factor VIII would be utilized in patients with hemophilia A. Thrombin causes blood coagulation by converting fibrinogen to fibrm. Thrombin is indicated for epistaxis, but is not a treatment for ITP.
Another important thought intramuscular injections should be avoided in patients with ITP.
Question 10.
Which of the following is an electrocardiogram change consistent with hypercalcemia?
(a) Prolonged QT interval
(b) Inverted T waves
(c) Ventricular tachycardia
(d) Prolonged PR interval
Answer:
(a) Prolonged QT interval
Rationale:
Ions such as calcium are essential for con-ducting electrical current through the cardiac muscle. When ionized serum calcium levels increase, prolonged QT intervals occur. T-wave inversion is a change seen in hypocalcemia. Patients with low magnesium levels will have ventricular dysrhythmias. A prolonged PR interval is a characteristic finding of hypokalemia.
Hypercalcemia is usually seen in adult T-cell lymphoma and multiple myeloma. Additional causes include hyperparathyroidism, use of thiazide diuretics, hyperthyroidism, Addison’s disease, renal failure, and excessive consumption of calcium. Treatment is aimed at identifying the underlying cause while preventing cardiac rhythm disturbances.
Question 11.
Disseminated Intravascular Coagulation (DIC) is characterized by the following EXCEPT:
(a) microvascular clots.
(b) increased clotting factors.
(c) decreased platelets.
(d) impaired hemostasis.
Answer:
(b) increased clotting factors.
Rationale:
In Disseminated Intravascular Coagulopathy (DIC), both thrombosis and fibrin degradation occur simultaneously, leading to widespread bleeding along with abnormal clotting in the microcirculation. DIC involves inappropriate and accelerated activation of the coagulation cascade manifested by impaired hemostasis and a depletion of platelets and clotting factors.
Question 12.
An immunocompromised patient presents to the emergency department on the advice of a primary physician, based on which of the following physiologic criteria?
(a) Elevated neutrophil count
(b) Wound with purulent drainage
(c) Warm, red, swollen insect bite
(d) Temperature > 100.4° F/38° C
Answer:
(d) Temperature > 100.4° F/38° C
Rationale:
The most significant indicator of infection in an immunocompromised person is fever. Thus, this population is instructed to seek medical care whenever the body temperature reaches 100.4° F/38° C. Immunocompromised patients become neutropenic (decreased neutrophils) end leukemic (decreased total white blood cell count). “The body’s phagocytic response is suppressed, because the body does not recognize the presence of an infection by typical symptoms such as heat, redness, swelling, and pus at the site of infection.
Patients who are immunocompromised are at greater risk of infection, even from normal body flora, as well as from an opportunistic source.
These patients should be isolated from the main population of the ED, provided with a face mask to reduce inhaling potentially communicable diseases or, ideally, placed in reverse isolation. Neutropenic patients with fever are considered to be having a medical emergency, and the patient should be iso-lated from other patients and prioritized for medical evaluation in the ED setting. These patients should not be sent to the waiting room in a triage situation! The waiting room is full of infectious agents!
Question 13.
In sickle cell crisis, the red blood cells containing hemoglobin S change shape to become a/an:
(a) crescent.
(b) disc.
(c) oblong.
(d) figure 8.
Answer:
(a) crescent.
Rationale:
When cells containing hemoglobin S are deoxygenated, the cell changes its shape from a disc to a crescent. These cells become rigid, cannot travel through the microvasculature, and obstruct capillary blood flow, resulting in extensive tissue hypoxia which further exacerbates deoxygenation and increases sick-ling of the red blood cells. Red blood cells with normal hemoglobin are disc-shaped. Red blood cells do not take an oblong or figure-8 shape.
Oxygen can quickly reverse the sickling process in a large percentage of hemoglobin S-affected cells. Pa-tients should be placed on supplemental oxygen as an immediate priority intervention. Hydroxyurea, a cytotoxic drug, can be used to treat sickle cell anemia. It creates hemoglobin F (HgbF), which is fetal hemoglobin and does not carry the mutation that causes the cells to sickle. Crises are less frequent and less severe with this medication.
Question 14.
Which of the following are clinical indicators of hypomagnesemia?
(a) Muscle weakness
(b) Prolonged QT interval
(c) Loss of deep tendon reflexes
(d) Muscle tetany
Answer:
(d) Muscle tetany
Rationale:
When serum magnesium is low, the threshold for stimulation is decreased and nerve conduction velocity is increased, leading to an increase in the excitability of muscles and nerves. This can produce muscle cramps, fasciculations, and tetany. Muscle weakness and loss of deep tendon reflexes, as well as prolonged QT interval in ECG, are indicative of hypermagnesemia.'
Question 15.
When administering intravenous magnesium, the emergency nurse should take which of the following actions?
(a) Administer the infusion slowly.
(b) Dilute the solution with normal saline only.
(c) Administer narcotics at routine dose strength.
(d) Monitor pulse and blood pressure every 4 hours.
Answer:
(a) Administer the infusion slowly.
Rationale:
Magnesium sulfate must be infused slowly at a rate not to exceed 125 mg/kg/hour to avoid potential cardiac or respiratory arrest. Normal saline or 5 % dextrose should be used to dilute the infusion. Caution should be used when administering CNS depressants such as narcotics and barbiturates because they ' potentiate the central nervous system depressant effect of magnesium. Patients being treated with intravenous mag-nesium sulfate should be placed on continuous cardiac/ respiratory monitoring.
Question 16.
A comatose patient arrives by ambulance to the emergency department. Assessment reveals a prolonged QT interval on electrocadiogram (ECG) and absent deep tendon reflexes.
Vital signs are as follows:
Blood pressure—86/52 mm Hg
Pulse—54 beats/minute
Respirations—8 breaths/minute
Temperature—98.2° F (36.7° C)
Pulse oximetry—94% on room air
The emergency nurse suspects which of the following electrolyte abnormalities?
(a) Hypokalemia
(b) Hyperkalemia
(c) Hypermagnesemia
(d) Hypomagnesemia
Answer:
(c) Hypermagnesemia
Rationale:
Elevated magnesium levels depress central and peripheral neuromuscular transmission affecting smooth, cardiac, and skeletal muscles, therefore displaying prolonged QT intervals and absent deep tendon reflexes. Depressed respirations, hypotension, and bradycardia are also part of this picture. If magnesium levels are below normal, muscle spasms, including tetany, may be evident, along with hyperreflexia, ST depression/T-wave elevation, and hypertension.
ECG changes associated with hypokalemia include ST segment and T-wave depression, premature atrial and ventricular contractions, and second- or third- degree heart block. In hyperkalemia, patients can be hyper- excitable, and ECG changes demonstrate peaked, elevated T waves, prolonged PR intervals, and a wide QRS complex.
Question 17.
A patient without human immunodeficiency virus (HIV) infection has a tuberculin skin test (purified protein derivative [PPD]). Which of the following is considered a positive result?
(a) Redness >10 mm
(b) Induration >10 mm
(c) Redness of 5 mm
(d) Induration of 5 mm
Answer:
(b) Induration >10 mm
Rationale:
If a patient has HIV infection, induration of 5 mm or more is considered a positive result. Induration 10 mm or more is considered a positive PPD result in the absence of HIV infection. Redness may be related to an allergic process but is not considered a positive PPD finding. If a patient has HIV infection, induration of 5 mm or more is considered a positive result.
Question 18.
Which of the following electrolyte abnormalities is commonly experienced by a patient in adrenal crisis?
(a) Hypocalcemia
(b) Hypernatremia
(c) Hyperglycemia
(d) Hyperkalemia
Answer:
(d) Hyperkalemia
Rationale:
Potassium elevation occurs in adrenal crisis because of an inability to regulate aldosterone, result-ing in sodium and water depletion and retention of potassium. These patients frequently have hyponatre-mia in conjunction with hyperkalemia. Patients with Addison’s disease aldjp have low cortisol production, inhibiting the breakdown of sugar into glucose, resulting in hypoglycemia. Hypocalcemia is related to low levels of mineralocorticoids, unrelated to aldosterone production.
Addison’s disease can be a very difficult to diagnosis because of the vagueness of the symptoms. The triad of laboratory results that can help to pinpoint this diagnosis is Hypoglycemia, Hyponatremia, and Hyperkalemia.
Question 19.
Which of the following statements would suggest that the patient diagnosed with mononucleosis understands their condition?
(a) “I can share eating utensils with others as long as I don’t have a fever.”
(b) “I need to avoid strenuous activity and contact sports for a month. ”
(c) “A vaccination would have prevented me from contracting this.”
(d) “This is an inherited disease and there is nothing I can do about it.”
Answer:
(b) “I need to avoid strenuous activity and contact sports for a month. ”
Rationale:
Splenomegaly occurs frequently in mono-nucleosis. Because of the risk of injury to an enlarged spleen, strenuous activity and contact sports should be avoided for at least 4 weeks. The virus is shared primar-ily via saliva and oropharyngeal route. Sharing eating utensils or food, kissing, and similar actions should be avoided during the incubation period of up to 60 days. There is no vaccine to prevent mononucleosis. It is a communicable virus, not a hereditary disorder.
Aspirin is also contraindicated for those children diagnosed with mononucleosis. Remember that mononucleosis is a viral disease caused by the Epstein-Barr virus. The use of aspirin in children with a viral illness can cause Reye’s syndrome.
Question 20.
Which of the following is the priority nursing intervention for a patient with bone pain related to leukemia?
(a) Send blood for a complete blood count (CBC).
(b) Place the patient in a private room.
(c) Administer narcotics for pain control.
(d) Send the patient for a computed tomography (CT) scan.
Answer:
(b) Place the patient in a private room.
Rationale:
Patients with leukemia are at high risk of contracting an infection, which can be lethal. Patients with such conditions should be immediately placed in reverse isolation to reduce the risk of infection. Obtaining laboratory studies, administering pain medication, and obtaining radiology studies may be indicated, but are not an immediate priority of care.
Question 21.
A 45-year-old patient arrives in the emergency department complaining of fever for the past 2 days. He is awake, alert, and oriented with the following vital signs:
Blood pressure—124/74 mm Hg
Heart rate—120 beats/minute
Respirations—22 breaths/minute
Pulse oximetry—94% on room air
Temperature—101.6° F (38.7° C)
He reports that he is HIV positive and taking antiviral medications. The emergency nurse should triage him at which acuity level using a 5-level system?
(a) Level 1 (resuscitation or life-threatening)
(b) Level 2 (high risk and/or emergent)
(c) Level 3 (urgent)
(d) Level 4/5 (nonurgent/nonemergent)
Answer:
(b) Level 2 (high risk and/or emergent)
Rationale:
Human immunodeficiency virus (HIV) posi-tive patients with fever are at high risk for deterioration and should be prioritized to an immediate open bed. The patient requires a workup to determine the source of fever and should be protected from other patients who may have a communicable infectious condition. This patient is not unresponsive, apneic, or in need of any life-saving interventions upon arrival, thus does not meet criteria for a level 1 acuity.
Level 3 patients require two or more resources according to the Emergency Severity Index (ESI) algorithm, but his immunocompromised condition escalates his acuity to level 2. Level 4 patients require only one resource and this patient will clearly need multiple resources to identify the source of, and treat, the fever. In a 5-level system, level 5 requires no resources.
On the actual test, questions may not be asked that are specific to the ESI; however, triage questions will be present. It is important to acknowledge proper understanding of triage priorities. Always remember to think “Is this patient high risk?" and move Ihem . up the scale. Also remember that any patient that requires “resuscitation,” whether that is in the form of cardio-pulmonary resuscitation (CPR) or the need for immediate fluid resuscitation, airway management, and so on, is in the resuscitation category now.
Question 22.
Which of the following is an age-specific consideration for children with sickle cell disease (SCD)?
(a) Routine childhood vaccinations are not recommended.
(b) Ischemic stroke is a high-frequency complication.
(c) Symptoms of SCD are present at birth in affected children.
(d) Attacks will decrease as the child enters adulthood.
Answer:
(b) Ischemic stroke is a high-frequency complication.
Rationale:
In sickle cell disease (SCD), the crescent-shaped (sickled) cells become rigid when deoxygen- ated and cannot pass through the microcirculation, obstructing capillary blood flow. In the cerebral blood vessels, occlusion can lead to ischemic stroke. Children with SCD are at high risk for infection and should receive all routine childhood immunizations. Fetal hemoglobin is protective during the first 6 months of life, after which SCD becomes evident. There is no evidence that SCD diminishes over time. A person may experience cluster attacks or go month or even years without an attack.
Screening for HbS at birth is currently mandatory in the United States. This method of case finding allows institution of early treatment and control. Obtaining a series of baseline values on each patient to compare with those at times of acute illness is useful.
Question 23.
An elderly patient arrives in the emergency department with a 3-cm laceration on the lower leg. The patient’s history reveals daily intake of warfarin (Coumadin). Which of the following complications should the nurse educate the patient about?
(a) Prolonged muscle weakness
(b) Decreased prothrombin time
(c) Prolonged wound healing
(d) Decreased renal clearance
Answer:
(c) Prolonged wound healing
Rationale:
The aging process results in dermatologic changes, including a loss of subcutaneous fat, skin elasticity and strength, compounded by the increased bleeding time because of the warfarin. All of these factors contribute to extended wound healing time. Muscle weakness develops in the elderly, but there is no indication it is a factor in this situation. The effect of warfarin is to prolong the prothrombin time (PT) by interfering with the synthesis of clotting factors. Renal clearance is not a direct complication of a laceration.
Question 24.
A petechial rash and fever are common symptoms of which of the following infectious diseases?
(a) Lyme disease
(b) Meningococcemia
(c) Varicella zoster
(d) Measles
Answer:
(b) Meningococcemia
Rationale:
Meningococcemia is characterized by a rapid onset of fever, petechial rash, and purpura. Death can occur within hours of onset because of coagulopathies and sepsis. Lyme disease symptoms become evident approximately 1 week after being bitten by an infected deer tick, typically a “bull’s-eye” rash around the site of the bite and flu-like symptoms. A purulent vesicular rash that originates on the trunk before becoming generalized characterizes a varicella zoster infection. The onset of measles symptoms is between 7 and 14 days after exposure and is characterized by a high fever and the three “Cs” (cough, coryza, and conjunctivitis). The red, macular rash begins on the face and spreads to the trunk and extremities.
Question 25.
Which of the following is the most serious complication associated with adrenal insufficiency (Addison’s disease)?
(a) Hypertensive crisis
(b) Myocardial infarction
(c) Intracranial bleed
(d) Hypovolemic shock
Answer:
(d) Hypovolemic shock
Rationale:
Patients with mineralocorticoid insufficiency may exhibit signs of sodium and volume depletion (for example, orthostatic hypotension and tachycardia). Additional symptoms include abdominal pain, fever, and confusion. Adrenal insufficiency is characterized by hypotension, not hypertension. Although conduction abnormalities such as prolonged PR or QT intervals may occur and alterations in serum potassium may produce a lethal dysrhythmia, myocardial infarction is not a primary complication. Intercranial bleeding is not associated with adrenal insufficiency.
Question 26.
Priority interventions for a patient with acute adrenal insufficiency (Addison’s disease) include all of the following EXCEPT:
(a) administration of intravenous (IV) antibiotics.
(b) rapid infusion of a crystalloid solution.
(c) continuous vital sign monitoring.
(d) administration of intravenous (IV) hydrocortisone (Solu-Cortef).
Answer:
(a) administration of intravenous (IV) antibiotics.
Rationale:
Adrenal insufficiency is an endocrine disorder and does not require antibiotic therapy unless there is evidence of an underlying infection. It is not a priority intervention. Hypovolemic shock is a life-threatening complication of acute adrenal insufficiency and requires aggressive fluid resuscitation. Additional priority interventions include administration of exogenous corticoids such as hydrocortisone (Solu-Cortef) or dexamethasone (Decadron). Vital signs should be continually monitored during the initial treatment phase.
The administration of hydrocortisone (Solu-Cortef) could cause inaccuracies with a cortisol level if it is desired. This would be a diagnostic test to confirm the diagnosis. The administration of dexamethasone (Decadron) would not interfere with the test.
Question 27.
A patient arrives in the emergency department with a potential anaphylactic reaction after eating peanuts.
The patient has edematous lips, urticaria, and inspiratory stridor. Vital signs are as follows:
Blood pressure—86/60 mm Hg
Heart rate—116 beats/minute
Respirations—24 breaths/minute
Pulse oximetry—94% on room air
Temperature—98.4° F (36.8° C)
After administering epinephrine (Adrenaline), the emergency nurse can anticipate an order for which of the following types of medication?
(a) Corticosteroid
(b) Beta-blocker
(c) Histamine-2 blocker
(d) Antibiotic
Answer:
(c) Histamine-2 blocker
Rationale:
Studies have shown the combination of an H,-blocker such as diphenhydramine (Benadryl) and an H2-blocker such as famotidine (Pepcid) to be superior to an Hrblocker alone in relieving the histamine-mediated symptoms of anaphylaxis. Corticosteroids have no immediate effect on mitigating anaphylaxis. Beta-blockers may increase the risk of anaphylaxis and inhibit the therapeutic effect of epinephrine in treating anaphylaxis. There is no value to administration of antibiotics in treating anaphylaxis because it is not an infectious process.
Question 28.
Which of the following medications can interfere with the compensatory physiologic response to anaphylaxis?
(a) Ceftriaxone (Rocephin)
(b) Metoprolol (Lopressor)
(c) Omeprazole (Prilosec)
(d) Diphenhydramine (Benadryl)
Answer:
(b) Metoprolol (Lopressor)
Rationale:
Beta-blockers such as metoprolol (Lopressor) may increase the risk of anaphylaxis. They inhibit the therapeutic effect of epinephrine in treating anaphylaxis by not allowing the beta-receptors to accept the betar and beta2-adrenergic effects of epinephrine. Ceftriaxone (Rocephin) is an antibiotic and has no effect on anaphylaxis. Omeprazole (Prilosec) is a proton-pump inhibitor (PPI) that does not impact beta-receptors. Diphenhydramine (Benadryl) is an histamine-1 (H^-antihistamine and is used in the treatment of itching and hives associated with an allergic reaction.
Patients taking beta-blockers who develop anaphy-laxis may not respond to epinephrine administration, and refractory hypotension commonly occurs. Glucagon has inotropic and chronotropic effects that do not rely on beta-receptors and can be used. Use caution when administering glucagon, because it can induce vomiting. The emergency nurse should protect the patient’s airway by placing them in the lateral recumbent position and have airway, suction and intubation equipment on hand.
Question 29.
Which of the following electrocardiogram (ECG) changes would the emergency nurse expect to see in a patient with a potassium level of 8.5 mEq/mL?
(a) Tall P waves
(b) Narrow QRS complex
(c) Shortened PR interval
(d) Peaked T waves
Answer:
(d) Peaked T waves
Rationale:
Elevated serum potassium levels cause tall, peaked T waves on the electrocardiogram. Elevated potassium can cause the P wave to disappear, not become tall. It also causes the QRS complex to widen, not narrow. PR intervals are lengthened when serum potassium is elevated.
Question 30.
When discharging a patient from the emergency department with a diagnosis of hepatitis A, the emergency nurse knows the patient understands his condition based on which of the following statements?
(a) “I got this disease from a dirty needle stick.”
(b) “I will be out of work for 14 days.”
(c) “I can donate blood in 4 weeks.”
(d) “My family can get vaccinated for hepatitis A.”
Answer:
(d) “My family can get vaccinated for hepatitis A.”
Rationale:
Hepatitis A vaccine is an inactivated (killed) vaccine that can be administered up to 21 days postex-posure. Hepatitis A is transmitted via the fecal-oral route. Hepatitis B and C can be transmitted through a dirty needle stick. Hepatitis A symptoms may last from 2 weeks to 6 months, and the infected person may be too ill to work. Blood banks will not accept blood during the acute phase of the illness, and up to 1 year in some cases.
Hepatitis A vaccination requires 2 doses for long-lasting protection. These doses should be given at least 6 months apart. Children are routinely vaccinated between their first and second birthdays (12 through 23 months of age). Older children and adolescents can get the vaccine after 23 months. Adults who have not been vaccinated previously and want to be protected against hepatitis A can also receive the vaccine.
Question 31.
Hemophilia A is characterized by a genetic deficiency of which clotting factor?
(a) Factor IX
(b) Factor VIII
(c) Factor XI
(d) Factor IV
Answer:
(b) Factor VIII
Rationale:
Hemophilia A is caused by a deficiency of functional plasma clotting factor VIII. An absence of factor IX results in hemophilia B, also called Christmas disease. Hemophilia C, or Rosenthal syndrome, is caused by a deficiency of factor XI. Factor IV is ionized calcium and is required in many stages of the coagulation cascade.
Von Willebrand’s disease is a form of hemophilia that occurs due to a lack of von Willebrand’s factor as well as deficiency of factor VIII in the clotting cas-cade. This form is unique in that females can have this genetic defect. They may have increased mucocu-taneous bleeding as well as heavy menstrual periods.
Question 32.
Emergency nursing interventions for a hematoma or hemarthrosis due to hemophilia include all of the following EXCEPT:
(a) application of warm packs.
(b) immobilization of the area.
(c) elevation of the extremity.
(d) application of a compressive dressing.
Answer:
(a) application of warm packs.
Rationale:
Cold, not warm, packs, should be applied to hematomas or a joint with hemarthrosis to increase vasoconstriction and slow bleeding. Immobilization of the affected area, elevation of an extremity, and the use of a mild compressive dressing are appropriate interventions.
Question 33.
A patient being discharged from the emergency department after treatment for hemophilia demonstrates understanding of his condition with which of the following statements?
(a) “I can tell the gang that I can play touch football next weekend. ”
(b) “If I need to I can take aspirin for my pain.”
(c) “I will arrange for prophylactic care before having dental treatments. ”
(d) “I will avoid extremes of hot and cold weather.”
Answer:
(c) “I will arrange for prophylactic care before having dental treatments. ”
Rationale:
Hemophiliac patients should prepare for dental procedures such as extractions by consulting both the dentist and their hematologist for clotting factor replacement therapy, antifibrinolytic agents, and local hemostatic measures. Patients with hemophilia should avoid contact sports. Over-the-counter medications containing aspirin or NSAIDs, which can precipitate or prolong bleeding, should be avoided. Temperature extremes do not influence hemophilia.
Question 34.
Interventions for a post-organ transplant patient coming to the emergency department complaining of a fever include all of the following EXCEPT:
(a) identification of the source of infection.
(b) placing the patient in a private room.
(c) restricting fluids and food.
(d) initiating antibiotic therapy quickly.
Answer:
(c) restricting fluids and food.
Rationale:
Fever can result in dehydration. Oral fluids as tolerated should be encouraged, and intravenous ac-cess should be initiated for administration of crystalloid solutions and medications. Post-transplant patients face a lifetime of taking immunosuppressant medications to prevent organ rejection. It is important to isolate the patient from others in the emergency department environment. Cultures of urine and blood and other likely sources of infection should be obtained. Antibiotics should be initiated within 1 hour of arrival in the emergency department.
Question 35.
Which of the following pharmacologic therapies should the emergency nurse anticipate administering to a patient with thyroid storm?
(a) Aspirin
(b) Propylthiouracil (PTU)
(c) Levothyroxine (Synthroid)
(d) Morphine sulfate
Answer:
(b) Propylthiouracil (PTU)
Rationale:
Thyroid storm is characterized by extremes of hyperthyroidism. Propylthiouracil (PTU) blocks thyroid hormone synthesis. Fever is a common symptom in thyroid storm and should be treated with cooling measures and antipyretics. However, aspirin should be avoided because it can increase thyroid hormone levels. Levothyroxine (Synthroid) is a synthetic replacement for thyroid hormone to treat hypothy-roidism, not thyroid storm. Morphine sulfate is an opioid analgesic and is not indicated in the treatment of thyroid storm.
PTU inhibits the synthesis of new thyroid hormone bat is ineffective in blocking the release of thyroid hormone. Iodide will bind with existing thyroid hormone. Always wait 1 hour after the loading dose of PTU has been given to administer iodine to prevent the utilization of iodine in the synthesis of new thyroid hormone.
Question 36.
The classic presentation of thyroid storm includes all of the following EXCEPT:
(a) fever.
(b) tachycardia.
(c) hot, dry skin.
(d) mentation changes.
Answer:
(c) hot, dry skin.
Rationale:
Patients in thyroid storm are heat-intolerant and sweat excessively, which, along with vomiting and fever, can exacerbate volume loss leading to hypovolemic shock. Patients in thyroid storm typically have a core body temperature of 101.3° F (38.5° C) due to the body’s increased metabolic rate. Hyperpyrexia (core temperature greater than 104° F [40° C]) can occur. Mental status changes, seizures, and coma are commonly seen in this condition. Tachycardia is a classic sign of thyroid storm.
Question 37.
A patient is being seen in the emergency department with herpes zoster. The appropriate staff member to care for this patient would be a nurse who has never had:
(a) pertussis.
(b) chicken pox.
(c) mumps.
(d) measles.
Answer:
(b) chicken pox.
Rationale:
Herpes zoster is caused by the reactivation of a dormant varicella (chickenpox) virus. Vesicular lesions develop along a nerve dermatome and contain the live virus. It is contagious to unvaccinated or sus-ceptible hosts. A person who has not had chickenpox may be susceptible to the virus and become ill. Pertussis is caused by the Bordetella pertussis organism. The measles and mumps viruses are not harbored in the body after the infection clears.
Question 38.
Which of the following is a common finding in a patient experiencing hyperosmolar hyperglycemic syndrome (HHS)?
(a) Glucosuria
(b) Anuria
(c) Hypertension
(d) Bradycardia
Answer:
(a) Glucosuria
Rationale:
Excess glucose is excreted via the urine.
The patient will exhibit polyuria, not anuria, as the body draws out water to dilute the elevated blood glucose. The resulting dehydration will cause tachycardia and hypotension, leading to hypovolemic shock if untreated.
Hyperosmolar hyperglycemic syndrome (HHS) is a complication of type 2 diabetes mellitus. Patients produce enough insulin to prevent ketosis but not enough to control blood glucose when HHS is trig-gered. This used to be called HHNC—Hyperosmolar Hyperglycemic Non-Ketotic Coma—but not everyone goes into a coma so they changed the terminology!
Question 39.
Which of the following parenteral solutions should be used in the initial treatment of intracellular fluid deficit of a patient with hyperosmolar hyperglycemic syndrome?
(a) D5W with 0.9% normal saline (NS)
(b) D5W with 0.45% normal saline (NS)
(c) 0.9% NS with 20 mEq potassium chloride
(d) 0.9% normal saline (NS)
Answer:
(d) 0.9% normal saline (NS)
Rationale:
Fluid deficit can exceed 10 L in Hyperosmolar Hyperglycemic Syndrome (HHS). Rapid rehydration with 0.9 normal saline (NS) is required to prevent circulatory collapse. Solutions containing dextrose are not indicated in the initial treatment of HHS but may be considered once serum glucose reaches 250 to 300 mg/dL. Serum potassium levels are generally within normal limits initially but should be monitored as the serum glucose levels decrease. Supplemental potassium can be added as needed.
Question 40.
Which of the following is the most critical complication resulting from hypoglycemia?
(a) Thiamine deficiency
(b) Brain dysfunction
(c) Acidosis
(d) Hypothermia
Answer:
(b) Brain dysfunction
Rationale:
Hypoglycemia is characterized by a reduction in plasma glucose concentrations. At low serum glucose levels, the brain is unable to extract oxygen, resulting in hypoxia, altered mental status, and potential brain damage. Thiamine deficiency may result if the patient is malnourished, but it is not a primary complication. Acidosis is not a complication of hypoglycemia. Patients may develop hyperthermia or hypothermia because of a decreased serum glucose level, but it is not a critical complication.
Question 41.
Which of the following is an intrarenal cause of acute kidney injury (AKI)?
(a) Episode of hypovolemia
(b) Development of neurogenic bladder
(c) Onset of renal calculi
(d) Nonsteroidal anti-inflammatory drugs (NSAIDs)
Answer:
(d) Nonsteroidal anti-inflammatory drugs (NSAIDs)
Rationale:
Intrarenal acute kidney injury (AKI) is the result of damage to the body of the kidney because of prolonged hypoperfusion and immunologic or inflammatory processes. Chronic use of NSAIDs can be directly nephrotoxic to kidney tissue. Decreased blood flow from hypovolemia is a prerenal cause of AKI, and neurogenic bladder and renal calculi, which obstruct the flow of urine out of the bladder or kidney, are postrenal causes of AKI.
Question 42.
Which of the following is the most significant early diagnostic test for acute kidney injury (AKI)?
(a) Urinalysis
(b) Creatinine
(c) Hemoglobin
(d) Potassium
Answer:
(a) Urinalysis
Rationale:
An abnormal urinalysis, with a reddish-brown color, suggesting the presence of myoglobin or hemoglobin, red blood cells, uric acid, and calcium oxalate crystals, is an early finding of acute kidney injury (AKI). An elevated serum creatinine, changes in hemoglobin levels, and alterations in serum potassium are later indications of AKI.
Watch your questions closely for words like “early"! These will make a 'difference in how the question will be answered. As in the above question all potential answers are correct but only one was the “early" sign.
Question 43.
Which of the following is a clinical feature of hypercalcemia?
(a) Hyperreflexia
(b) Weight loss
(c) QT prolongation
(d) Anuria
Answer:
(b) Weight loss
Rationale:
Patients with hypercalcemia often complain of weight loss because of anorexia, nausea, vomiting, and constipation. Hyperreflexia is a symptom of hypo-magnesemia. QT prolongation is frequently observed in hypocalcemia. Anuria is defined in the adult population as a passage of less than 50 mL of urine/day and is a complication of acute kidney injury.
Hypercalcemic patients are often lethargic, confused, and hypertensive, and may have psychiatric manifestations such as psychotic episodes. They may also have impaired memory, feel fatigued, and have decreased muscle strength and reflexes.
Question 44.
A patient in the emergency department is being evaluated for acute kidney injury (AKI) and appears very ill. A urinalysis and complete blood count (CBC) have been ordered. Which of the following additional tests would be most beneficial to determine the severity and acuity of renal failure and would require immediate life-saving interventions?
(a) Intravenous pyelogram (IVP)
(b) Blood urea nitrogen (BUN)
(c) Renal arteriogram
(d) Serum potassium
Answer:
(d) Serum potassium
Rationale:
The most common electrolyte imbalances seen in acute renal failure are hyperkalemia, hyponatremia, hypocalcemia, and hyperphosphatemia. Hyperkalemia is a life-threatening electrolyte disturbance requiring immediate treatment. An intravenous pyleogram visualizes abnormalities of the urinary system, including the kidneys, ureters, and bladder, and evaluates the flow of urine through the renal system. Renal angiography can be helpful in establishing the etiology of renal vascular diseases, including renal artery stenosis, but does not assist in determining the severity or acuity. An elevated blood urea nitrogen (BUN) is a hallmark of acute kidney injury but is not considered a life-threatening condition.
Question 45.
A patient’s laboratory results indicate a sodium value of 106 mEq/mL. Which of the following would be the primary complication for the emergency nurse to anticipate?
(a) Tetany
(b) Seizure activity
(c) Decreased urinary output
(d) Profound bradycardia
Answer:
(b) Seizure activity
Rationale:
Normal sodium levels range between 135 and 145 mEq/mL. When serum sodium levels fall below 120 mEq/L, symptoms of hyponatremia appear. An altered level of consciousness ranging from confusion to coma and seizures are commonly seen. Tetany is a serious complication of hypocalcemia. Decreased urinary output (less than 500 mL of urine/24 hours in an adult) is seen in both acute kidney injury and chronic renal failure. Tachycardia, not bradycardia, is seen in hyponatremia.
Hyponatremia can result from either a-depletion of serum sodium or a dilution of sodium in the vascular system. 1featment of hyponatremia is to gradually replace sodium. The intravenous treatment is an IV infusion of 0.9% normal saline or hypertonic (3%) saline solution. Hypertonic saline can be dangerous! This is only given when sodium levels are extremely low (less than 110 mEq/mL) and needs' to be stopped when symptoms are seen to be improving—not waiting for the numbers to return to normal!
Question 46.
A patient with chronic renal failure requires multiple units of packed red blood cells. The emergency nurse should monitor the patient for:
(a) hypocalcemia.
(b) hypokalemia.
(c) increased white blood cell count.
(d) decreased clotting time.
Answer:
(a) hypocalcemia.
Rationale:
Each unit of packed red blood cells (PRBCs) for transfusion contains approximately 3 mg of citrate as a preservative, which accumulates in'the blood where it binds to circulating calcium, thereby reducing plasma calcium concentration. Patients receiving more than 5 units of PRBCs should have serum calcium levels checked. These patients may require intravenous calcium chloride of calcium gluconate.
A patient receiving multiple transfusions of PRBCs would be at risk of hyperkalemia due to the breakdown of blood cells that release potassium while it is being stored. White blood cell counts are not impacted with administration of packed red cells. Clotting times may be increased because packed red cells do not contain any clotting factors. Replacement of platelets and fresh frozen plasma (FFP) should be considered when multiple units of PRBCs are infused.
Question 47.
Which of the following should be performed by the emergency nurse caring for a patient with suspected Herpes Zoster (shingles)?
(a) Place the patient in a negative-pressure room.
(b) Administer postexposure prophylaxis.
(c) Place the patient on contact precautions.
(d) Wear an N-95 respiratory mask.
Answer:
(c) Place the patient on contact precautions.
Rationale:
Herpes zoster is spread via direct contact with the herpetic lesions. Negative-pressure isolation is indicated for airborne, not contact, isolation. A patient who is already symptomatic will not benefit from postexposure prophylaxis. The N-95 respiratory mask is required for droplet infections such as tuberculosis.
Patients requiring contact isolation should be isolated in a single-patient area as soon as possible, caregivers should wear gloves anty gown during direct care, and disposable or dedicated patient-care equipment should be used. Patient movement outside of the treatment room should be limited. If transport is necessary, the infected areas of the patient’s body should be covered.
Question 48.
Which of the following two extracellular substances work together to regulate pH?
(a) Sodium bicarbonate and acetic acid
(b) Sodium bicarbonate and carbonic acid
(c) Sodium bicarbonate and sodium hydroxide
(d) Sodium bicarbonate and carbon dioxide
Answer:
(b) Sodium bicarbonate and carbonic acid
Rationale:
Sodium bicarbonate and carbonic acid are the two primary extracellular regulators of pH. pH is also further regulated by electrolyte composition within the intracellular and extracellular compartments. Acetic acid is commonly known as vinegar and is not an extracellular substance in the human body. Carbon dioxide combines with water to form carbonic acid. Sodium hydroxide is lye or caustic acid and is not found in the body.
pH remains normal if a ratio of 20 base to 1 acid is maintained. Bicarbonate is the base parameter and carbonic acid (which creates carbon dioxide) is the acid component.
Question 49.
Which of the following is a true statement regarding the characterization of an acid and a base?
(a) Acids release hydrogen (H + ) ions and bases accept H+ ions.
(b) Acids accept H+ ions and bases release H+ ions.
(c) Both acids and bases can release and accept H + ions.
(d) Acids can accept and release H+ ions, and bases accept H+ ions.
Answer:
(a) Acids release hydrogen (H + ) ions and bases accept H+ ions.
Rationale:
Acids are molecules that have the ability to release H + ions and bases are molecules that have the ability to accept or bind with H+ ions. Acids do not ac-cept H+ ions, and bases do not release H+ ions.
Question 50.
A patient demonstrates understanding of discharge instructions after being diagnosed with a latex allergy when stating “I know that I need to avoid many foods but its ok for me to eat:
(a) kiwi.”
(b) bananas.”
(c) olives.”
(d) tomatoes.”
Answer:
(c) olives.”
Rationale:
Approximately 50% of people with latex al-lergy have a history of another type of allergy. Food restriction for patients with latex allergies does not include olives. Certain fruits and vegetables, such as ba-nanas, chestnuts, kiwi, avocado, and tomato, can cause allergic symptoms in some latex-sensitive individuals be-cause of a possible cross-sensitization of the latex product in these plants.
Question 51.
Prerenal causes of acute kidney injury (AKI) include all of the following EXCEPT:
(a) anaphylaxis.
(b) sepsis.
(c) heart failure.
(d) renal artery stenosis.
Answer:
(d) renal artery stenosis.
Rationale:
Renal artery stenosis produces localized ischemia because of narrowed renal artery perfusion within the kidney. It is considered an intrarenal or intrinsic cause of acute kidney injury (AKI). Prerenal acute kidney injury results from decreased blood flow to the kidney, resulting in ischemia of the nephrons. Prolonged ischemia can lead to acute tubular necrosis and permanent renal damage. Profound, persistent systemic hypotension from anaphylaxis, sepsis, or heart failure are ;common causes of prerenal acute kidney injury.
Question 52.
Which of the following is the expected primary treatment outcome of postrenal acute kidney injury (AKI)?
(a) Increase outflow of urine from the kidney
(b) Increase renal artery perfusion
(c) Increase systemic blood pressure
(d) Decrease systemic blood pressure
Answer:
(a) Increase outflow of urine from the kidney
Rationale:
Postrenal acute kidney injury is the result of an obstruction of the urinary collection system from the calices of the kidney to the urethral meatus. Relief of the obstruction and allowing urine to flow out of ~ the kidney is the intention of treatment interventions. Increasing renal artery perfusion and increasing or de-creasing systemic blood pressure are interventions which influence prerenal acute kidney injury.
Question 53.
Which of the following is the normal range for arterial blood pH?
(a) 7.38 to 7.46
(b) 7.40 to 7.52
(c) 7.35 to 7.45
(d) 7.28 to 7.38
Answer:
(c) 7.35 to 7.45
Rationale:
Tight regulation of [H + ] is crucial for normal cellular activities. The body requires a pH of 7.35 to 7.45 to maintain homeostasis. pH values below 7.35 are reflective of acidosis and values in excess of 7.45 indicate alkalosis.
Question 54.
An elderly patient has an elevated temperature, restlessness, confusion, and weakness after a radioactive iodine treatment. The physician suspects thyroid storm. Which treatment option should the emergency nurse anticipate?
(a) Acetylsalicylate acid (Aspirin)
(b) Propranolol (Inderal)
(c) Atropine sulfate
(d) Sodium bicarbonate
Answer:
(b) Propranolol (Inderal)
Rationale:
Propranolol is the mainstay of treatment for this problem. This will decrease the heart rate and also prevents conversion of T4 to T3. The T3 state is the state in which thyroid hormone is utilized in the cells.
Propranolol can be administered orally, via nasogastric tube, or intravenously. Intravenous dosing is 0.5 to 1.0 mg over a 10-minute period of time and then 1.0 to 2.0 mg every few hours depending on heart rate and blood pressure readings. Aspirin has antipyretic properties, which is usually indicated for controlling fever, but in thyroid storm, aspirin is contraindicated as it can free up more thyroid hormone in the T3 state.
Atropine would increase the heart rate. Anticholinergics such as atropine are ineffective in controlling the rapid heart rate of thyroid storm, as it is a hypermeta- bolic state because of excessive thyroid hormone release. Sodium bicarbonate is a buffer for the acid-base system. Acidosis may develop in patients with thyroid storm due to their hypermetabolic condition, but sodium bicarbonate is not a primary treatment of thyroid storm.
Remember to avoid beta-blockers if the patient has asthma, chronic obstructive pulmonary disease, peripheral vascular disease, or decompensated heart failure. Also glucocorticoids are used in many of these crisis situations due to the increased use of cortisol, the stress hormone, during these episodes.
Question 55.
A patient with diabetes insipidus should be monitored for which of tjie following serum electrolyte imbalances?
(a) Hypoglycemia
(b) Hyponatremia
(c) Hypernatremia
(d) Hyperglycemia
Answer:
(c) Hypernatremia
Rationale:
Diabetes insipidus is caused by a defect in the secretion of antidiuretic hormone (ADH) or the kidney’s ability to concentrate urine. The patient ex-hibits polyuria and polydipsia. This water disturbance results in dehydration and hypernatremia. There is little to no effect on blood glucose values in diabetes insipidus. Patients with diabetes insipidus can pass large volumes (greater than 3 L/24 hour) of dilute urine, which concentrates serum sodium levels. Hyponatremia is not seen in this condition.
Question 56.
Which of the following systems in the body works fastest to regulate pH in acid-base balance?
(a) Renal
(b) Respiratory
(c) GI system
(d) Endocrine
Answer:
(b) Respiratory
Rationale:
Both the respiratory and renal systems work to regulate pH in acid-base imbalance; however, the respiratory system works in a matter of minutes and reaches its peak within 12 to 24 hours of the onset of an acid-base imbalance. The renal system also regu-lates acid-base balance; however, the onset of its effect is slower and the renal system will function for days to restore the pH to normal limits. The GI and endocrine systems have little or no effect on regulating acid-base balance.
The kidneys are able to affect blood pH by excreting excess acids or bases. The kidneys have some ability to alter the amount of acid or base that is excreted, but because the kidneys make these adjustments more slowly than the lungs, this compensation generally takes several days. The nice thing is that this system can eventually correct an abnormal pH, but the respiratory system, which deals with the carbon dioxide (acid) component, will not be able to totally compensate.
Question 57.
A mother brings her child in with a rash and fever and is diagnosed with measles. The mother is concerned about the children that she babysits for each day. Which of the following responses from the mother would indicate that proper education has been provided when the emergency nurse asks her to relay the proper incubation period for this disease process?
(a) 1 to 2 days
(b) 3 to 5 days
(c) 4 to 7 days
(d) 10 to 14 days
Answer:
(d) 10 to 14 days
Rationale:
Measles is a highly contagious illness caused by the Morbillivirus and is spread by coughing and sneezing via close personal contact or direct contact with secretions. The average incubation period from exposure to onset of the measles is 10 to 14 day. Patients are contagious from 1 to 2 days before the onset of symptoms. The patient can be infectious from 3 to 5 days before the appearance of the rash to 4 days after the onset of rash. The rash has an average duration of 4 to 7 days.
Question 58.
Which of the following is a complication of diphtheria?
(a) Inability to open the jaw
(b) Maculo-papular rash
(c) Difficulty swallowing
(d) Muscle spasms
Answer:
(c) Difficulty swallowing
Rationale:
The toxins released by diphtheria set up the development of a localized or coalescing pseudomembrane, which can occur in any portion of the respiratory tract, leading to difficulty breathing. The pseudomembrane is characterized by the formation of a dense, gray debris layer comprising a mixture of dead cells, fibrin, red blood cells (RBCs), white blood cells (WBCs) and organisms. The inability to open the jaw and muscle spasms are symptoms of tetanus, not diphtheria. Diphtheria does not produce a rash.
Question 59.
While assessing a febrile patient, the nurse notes pain in the hamstring muscle when the patient flexes and contracts the leg. This is symptomatic of which of the following disease processes?
(a) Guillain-Barre syndrome
(b) Meningitis
(c) Lumbar disc compression
(d) Multiple sclerosis
Answer:
(b) Meningitis
Rationale:
Meningeal irritation causes pain with flexion/extension of the leg (Kernig’s sign). Guillain- Barre is an acute peripheral neuropathy characterized by ascending muscle weakness and paralysis. There is no pain with flexion/extension of the hamstring muscle in Guillain-Barre. Lumbar disc compression is not accompanied by fever. Multiple sclerosis is characterized by intermittent episodes of neurologic symptoms such as
paresthesia, weakness, and visual disturbances, but not fever. Flexion/extension of the hamstring muscles does not induce pain with this patient population.
Another sign of meningitis (besides Kemig’s sign) is Brudzinski’s sign. This is elicited by flexing the neck and the hips and knees flex automatically at the same time. Nuchal rigidity can also be seen. This causes the neck to not be able to bend to touch the chin to the chest. All three of these signs are great, but they are not always demonstrable in all patients with meningitis.
Question 60.
A patient has been treated for diabetic ketoacidosis for the past 3 hours on an insulin drip. At present, the respiratory rate is 28 breaths/minute, as opposed to 44 breaths/minute on arrival, and the heart rate is 102 beats/ minute instead of the initial 140 beats/minute. On asking the patient how she feels, the patient responds that she is better but is complaining of a headache with a pain rating of 7 on a scale of 1 to 10. Which of the following is the most important response by the emergency nurse regarding the new complaint at this time?
(a) Obtain an order for acetominophen (Tylenol).
(b) Understand this is a normal reaction.
(c) Check the blood sugar.
(d) Take the patient’s temperature.
Answer:
(c) Check the blood sugar.
Rationale:
Blood glucose {should be decreased at a rate of 75 to 100 mg/dL/hour.i If the level is reduced too quickly, cerebral edema can occur. Blood glucose levels should be monitored hourly to make sure that the rate of decrease is not too great. This is not normal for treatment for diabetic ketoacidosis (DKA). Tylenol (Acetaminophen) can help but is not the priority. Considering the temperature will not impact this problem.
Question 61.
Which of the following is the major cause of anaphylaxis?
(a) Food products
(b) Latex
(c) Insect stings
(d) Exercise
Answer:
(a) Food products
Rationale:
Food is implicated in the largest percentage of anaphylactic episodes, causing approximately 13%
to 65% of all episodes. Latex is the cause of between 7% and 9% of anaphylactic reactions and has been steadily decreasing with the use of latex-free products, especially in the hospital setting. Insect stings account for 1 % to 7% of episodes. Exercise-induced anaphylaxis is rare, occurring in less than 1 % of the population.
In the Unites States, eight foods account for the ma-jority of food allergy reactions: milk, egg, peanut, tree nuts, soy, wheat, fish, and shellfish.
Question 62.
Which of the following would indicate treatment Tor pertussis (whooping cough) has been effective?
(a) Resolution of characteristic “whooping” cough and fever
(b) Completion of the prescribed antibiotic treatment
(c) Negative nasopharyngeal swap for Bordetella pertussis
(d) Negative reading of chest radiograph
Answer:
(c) Negative nasopharyngeal swap for Bordetella pertussis
Rationale:
A negative swab is the only definitive evi-dence that treatment has been effective. Despite reso-lution of fever and cough, pertussis infection may still be present in the body. Pertussis requires an extensive course of antibiotics, often up to 3 weeks. Pertussis is not detected on a chest radiograph.
Question 63.
Which of the following would indicate effective treatment for disseminated intravascular coagulopathy (DIC)?
(a) Hematuria is noted after initiating treatment.
(b) A venipuncture site does not bleed after 5 minutes.
(c) The platelet count is decreased.
(d) Coagulation times are increased.
Answer:
(b) A venipuncture site does not bleed after 5 minutes.
Rationale:
Return of a normal clotting time is an indication that appropriate and effective treatment has occurred, which would be indicated by a venipuncture site that is not bleeding within this period of time. Hematuria is a common physical finding in disseminated intravascular coagulation (DIC), along with hematemesis, occult blood in the stool, and prolonged bleeding from puncture sites. Platelets are decreased in DIC, and increasing the count is a goal of therapy. Coagulation times are prolonged in DIC. Goals of treatment are normal prothrombin time (PT) and partial thromboplastin time (PTT) values.
Question 64.
Nursing care of a patient with disseminated intravascular coagulopathy (DIC) includes all of the following EXCEPT:
(a) administration of medication via intramuscular route.
(b) pressure dressings to active bleeding sites.
(c) administration of intravenous heparin.
(d) limiting the number of venipunctures.
Answer:
(a) administration of medication via intramuscular route.
Rationale:
Intramuscular injections should be avoided to prevent bleeding and hematoma development at the injection site in a patient with disseminated intravas-cular coagulation (DIC). Pressure dressings will slow bleeding until the coagulopathy is corrected. Heparin is the drug of choice for treatment of DIC. It acts to inhibit thrombin development, preventing clot formation in the microvasculature. Venipunctures, injections, and other interventions that may disrupt the integrity of the skin should be avoided to prevent additional bleeding.
The most important treatment for DIC is correcting the underlying cause. DIC is a secondary response ‘ to a primary problem and there is always a disease process that needs to be corrected. Other treatment options include the replacement of clotting factors through the use of platelets, cryoprecipitate, and fibrinogen.
Question 65.
All of the following are symptoms of Clostridium difficile infection EXCEPT:
(a) bloody diarrhea.
(b) fever.
(c) crampy abdominal pain.
(d) anorexia.
Answer:
(a) bloody diarrhea.
Rationale:
Clostridium difficile infection is characterized by mild-to-moderate watery diarrhea that is rarely bloody. It has a characteristic odor and may contain mucous. Common symptoms seen in patients with C. difficile infection include fever, especially in severe cases, crampy abdominal pain and a loss of appetite.
Question 66.
Patients suspected of Clostridium difficile infection should be placed in which of the following types of isolation?
(a) Contact
(b) Droplet
(c) Airborne
(d) No isolation is needed.
Answer:
(a) Contact
Rationale:
Clostridium difficile is categorized as a health care-acquired infection. The spores can live on inanimate objects for up to 5 months. Caregivers should use contact precautions to prevent exposure to themselves and inadvertent transmission to other patients. Droplet precautions are indicated for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking. Use airborne precautions when caring for patients infected with known or suspected pathogens transmitted by the airborne route (tuberculosis, measles, chickenpox, herpes zoster, etc.).
It is important ta ^et patients placed into appropriate isolations as soon as possible! It takes more time and can be frustrating, but it most certainly needs to be done!
Question 67.
A vesicular rash and fever are indicative of which of ‘ the following infectious diseases?
(a) Kawasaki disease
(b) Varicella zoster
(c) Lyme disease
(d) Meningococcemia
Answer:
(b) Varicella zoster
Rationale:
Varicella zoster lesions are fluid-filled vesicles, most commonly affecting the thoracic dermatome. The patient may have flu-like symptoms with or without fever. A petechial rash of small, pinpoint lesions progressing rapidly to purpura is the characteristic manifestation of meningococcemia. Petechial and purpuric lesions develop from bleeding under the skin and do not blanch on applying pressure.
Fever has a sudden onset and rises quickly. Kawasaki disease is a rare childhood illness, which presents with a fever and rash of poorly defined spots of various sizes, often bright red that blanch when pressure is applied. The rash of Lyme disease begins at the site of a tick bite after a delay of 3 to 30 days (average is about 7 days). It expands gradually over a period of days reaching up to 12" or more (30 cm) across. As it enlarges, the center clears, resulting in a tar-get or “bull’s-eye” appearance.
Question 68.
Which of the following symptoms are indicative of measles?
(a) Pruritic rash to the chest
(b) Bluish-gray spots on the buccal mucosa
(c) Parotid gland enlargement
(d) Petechiae in the folds of the axilla
Answer:
(b) Bluish-gray spots on the buccal mucosa
Rationale:
Bluish-gray spots (Koplik spots) appear on the inside of the cheeks after 2 to 4 days of prodromal symptoms and are visible for up to 5 days. The rash of measles is maculopapular and first appears on the face. A pruritic rash to the chest is indicative of varicella (chickenpox). Parotid gland enlargement is characteristic of mumps. Petechiae in the skin folds of the axilla and groin are found in scarlet fever.
Question 69.
Allergic stings are most commonly caused by which of the following?
(a) Hornets
(b) Scabies
(c) Bumble bees
(d) Bed bugs
Answer:
(a) Hornets
Rationale:
Hornets, yellow jackets, and wasps are the leading cause of allergic stings. They are aggressive and can sting repeatedly with minimal provocation.
Scabies is an intensely itchy skin infestation caused by a mite. It does not produce an allergic reaction. Bumble bees can produce an allergic reaction but are much less aggressive and sting with much lower frequency. Bed bugs are parasitic insects that feed on blood. The bite produces a painless, pruritic lesion. Urticaria may de-velop from repeated exposure.
Question 70.
Causes of disseminated intravascular coagulation (DIC) include all of the following EXCEPT:
(a) sepsis.
(b) hemolytic transfusion reaction.
(c) idiopathic thrombocytopenia.
(d) transplant rejection.
Answer:
(c) idiopathic thrombocytopenia.
Rationale:
Idiopathic thrombocytopenia is a disease of increased peripheral platelet destruction, commonly seen in children several weeks after a viral infection such as chickenpox or rubella. DIC is a thrombohemor- rhagic disorder involving inappropriate and accelerated stimulation of the clotting cascade. Common causes in-clude sepsis, a hemolytic transfusion reaction, transplant rejection as well as massive blood transfusions, major trauma, and obstetrical complications such as abruptio placentae and retained placenta.
Question 71.
Immunotherapy for anaphylaxis can be given to people with allergies to which of the following agents?
(a) Peanuts
(b) Insect stings
(c) Milk
(d) Latex
Answer:
(b) Insect stings
Rationale:
Immunotherapy can provide significant im-provements in allergic symptoms and reduce the need for additional pharmacotherapy of insect stings and environmental allergens such as pollen. Immunotherapy has proven to have long-term benefits and is effective for desensitizing a person as a means of preventing reactions to subsequent stings. There are clinical trials using immunotherapy in peanut allergies, but it is not a proven therapy at this time. No specific immunologic therapy has been found to desensitize milk or latex allergies.
Question 72.
Which of the following is the hepatitis virus transmitted via the fecal-oral route?
(a) Hepatitis A
(b) Hepatitis B
(c) Hepatitis C
(d) Hepatitis D
Answer:
(a) Hepatitis A
Rationale:
Hepatitis A is transmitted primarily through the fecal-oral route, usually by person-to-person contact or by ingesting contaminated water or food. It is infectious 2 weeks before and 2 weeks after symptom onset.
Intravenous drug use and sexual contact are the primary transmission routes for hepatitis B. Blood transfusions are less frequently a source of transmission because of the careful screening of donated blood. Hepatitis C is also transmitted via IV drug use and from blood transfusions administered before testing of the blood supply. Hepatitis D is only found in patients with acute or chronic hepatitis B, because it is an incomplete virus and requires the hepatitis B virus to replicate. It is also transmitted via IV drug use or sexual contact.
Remember that there are vaccines available for hepatitis A and B but not for hepatitis C!
Question 73.
Which of the following statements made by a patient being discharged with a diagnosis of hepatitis would indicate that the patient understood their instructions?
(a) “I can eat anything I want even foods with high fat content.”
(b) “Other family members will not be able to use the same bathroom.”
(c) “It will be all right for me to drink alcohol every once in a while. ”
(d) “I will need to reduce my calorie intake from now on.”
Answer:
(b) “Other family members will not be able to use the same bathroom.”
Rationale:
Family members and close personal contacts should avoid using the same bathroom as a patient with a diagnosis of hepatitis to avoid exposure to body substances and fluids. This exposure can potentially transmit the hepatitis virus. Dietary instructions for a patient with hepatitis include a high-caloric, high-carbohydrate, low-fat diet. The patient should be instructed to eat small, frequent meals. Alcohol use is prohibited during the acute illness because it is metabolized in the liver.
Question 74.
A patient arrives in the emergency department with a slightly decreased level of consciousness and tachycardia. The glucometer reading is 42 mg/dL. He tells the emergency nurse that he has a past history, of alcoholism, cirrhosis, coronary artery disease, and pneumonia. All of the following would be appropriate measures for this patient EXCEPT:
(a) dextrose 50% intravenously.
(b) glucagon intramuscularly.
(c) place on cardiac monitor.
(d) perform frequent vital signs.
Answer:
(b) glucagon intramuscularly.
Rationale:
With a past history of alcoholism and cirrhosis, glucagon will most likely not work for this patient. Glucagon stimulates the liver to produce glucose, and with the liver involvement in this patient, it will probably not work. Providing intravenous glucose is appropriate. Patients with hypoglycemia should be placed on the cardiac monitor and have vital signs measured frequently in order to adequately watch the patient for signs of deterioration or improvement.
Once hypoglycemia is treated and the patient re-sponds, it is important to provide a meal so that the blood glucose level remains within a normal range. They need complex carbohydrates to maintain the sugar level.
Question 75.
Which of the following is the main route of transmission for infectious mononucleosis?
(a) Blood
(b) Skin lesions
(c) Stool
(d) Saliva
Answer:
(d) Saliva
Rationale:
The main causal agent of infectious mono-nucleosis is the Epstein-Barr virus. The usual route of transmission is oropharyngeal through saliva. Hence, its moniker as the “kissing disease.” The virus is not found in blood or stool. It is not passed by contact with skin lesions. Classic symptoms of mononucleosis include a flu-like prodromal period lasting 3 to 5 days followed by fever, pharyngitis, and lymphadenopathy. No rash is associated with mononucleosis.