Professional Issues CEN Questions with Rationale

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Professional Issues CEN Practice Questions - CEN Questions on Professional Issues

Question 1.
During a disaster, surge capacity is the hospital’s ability to manage a sudden influx of patients. Which of the following should the emergency department nurse do first in this situation?
(a) Initiate activation of the Emergency Operations Plan (EOP).
(b) Keep patients and visitors informed of the plan.
(c) Activate relevant specialty procedures (e.g., active shooter).
(d) Prioritize hazards, safety, and health issues.
Answer:
(a) Initiate activation of the Emergency Operations Plan (EOP).

Rationale: 
Although each of these items is important in safely and effectively managing surge, keeping patients and visitors informed, activating relevant procedures, and prioritizing hazards, safety, and health issues cannot be done unless (or until) the charge nurse acti-vates the plan.

Question 2.
The Joint Commission sentinel event alert related to preventing restraint deaths identified all of the following risks EXCEPT:
(a) Placing a restrained patient in a supine position could increase aspiration risk.
(b) placing a restrained patient in a prone position could increase suffocation risk
(c) A restraint may cause further psychological trauma or traumatic memories.
(d) Appropriate alternatives to restraints are to be used only as a last resort.
Answer:
(d) Appropriate alternatives to restraints are to be used only as a last resort.

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

Interactions that are calm, respectful, and collaborative can diminish the need for restraints. There are three distinct types of restraints; physical, chemical, and seclusion. Reduction of restraint use is a focus for many hospitals and health care facilities, and many hospitals now prohibit the use of medications for chemical restraint. It is important that ED nurses receive training in the application of each type of restraint as well as in ongoing competencies and review of new research regarding the use of restraints.

Question 3.
When the emergency nurse approaches the patient to draw blood and the patient rolls up his sleeve and holds out his arm, this type of consent would be considered to be;
(a) Express consent.
(b) Implied consent.
(c) Involuntary consent
(d) Informed consent.
Answer:
(b) Implied consent.

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

• Express consent can be expressed verbally or in writing when the patient arrives. The patient may simply say “I consent. ”
• Implied consent occurs through the actions or conduct of the patient, for example, by showing up at the agreed upon time for surgery. In the ED, it can be said that arriving to the triage window requesting care displays the patient's implied consent or providing the arm for phlebotomy or to have a laceration repaired.
• Informed consent means that the patient has been informed of the risks and dangers involved in a treatment and that the patient consents to this treatment. It is typically an agreement in writing, in which the patient’s signature is considered consent. The provider performing the procedure has the responsibility to inform the patient regarding the abovementioned information.
• Involuntary consent occurs when a patient is incapable of making prudent medical decisions because of injury or illness.

Question 4.
After a disaster has occurred, emergency department nurses assist with arranging counseling and looking for suitable housing for the victims. Which of the following would this type of prevention be considered? 
(a) Primary
(b) Secondary
(c) Tertiary
(d) Primordial
Answer:
(c) Tertiary

Rationale: 
The only possible answer is tertiary because the disaster has already happened. Tertiary prevention aims to minimize the ongoing lasting effects of the injury or illness to improve the quality of life and life expec-tancy. In disaster preparedness, this phase is designed to support the long-term effects of the catastrophe and help the community to “rebuild” both physically and psycho-logically. Primordial, primary, and secondary measures would no longer be relevant. Primordial prevention involves minimizing and or mitigation of the social, eco-nomic, and cultural patterns of living that contribute to an elevated risk of disease. Working to improve lifestyles to decrease obesity, smoking, and so on is an example of primordial prevention. This is done through individual and mass education. Primary prevention refers to risk reduction. It is concerned with preventing the onset of disease/disasters and to reduce the incidence of disease or disasters such as with vaccinations or banning the use of asbestos. Secondary prevention aims to reduce the impact of a disease or injury that has already occurred. Examples include routine mammograms, low-dose aspirin daily regimen, and light duty for workers to get back to work.

Question 5.
The ENA Code of Ethics believes that the emergency nurse should collaborate with other health professionals and the public to do all of the following EXCEPT:
(a) Protect human rights.
(b) Promote health diplomacy.
(c) Document restraints appropriately.
(d) Reduce health disparities.
Answer:
(c) Document restraints appropriately.

Rationale: 
Although documentation is always important (especially with restraints!), this answer is not ^ included in the ENA Code of Ethics. Protecting human rights, promoting health diplomacy, and working to reduce disparities in the health care realm are all parts of the Code of Ethics.

The American Nurses Association (ANA) recognizes the Nursing Code of Ethics to be a nonnegotiable and ethical standard of the nursing profession. This document serves as an expression of nursing’s commitment to society. Within the code, there are nine provisions. The Emergency Nurses Association (ENA) is recognized by the ANA as a specialty body of nursing.
The nine provisions are as follows:

• Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
• Provision 2: The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.
• Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the patient. 
• Provision 4: The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care. 
• Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
• Provision 6: The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
• Provision 7: The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. 
• Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
• Provision 9: The profession of nursing collectively, through its professional organizations must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.
• This Code of Ethics relates to the specialty of emergency nursing and serves as a point of reference for the emergency nurse to guide professional practice. For more details and interpretive statements about each pro-vision, see the "Nursing Code of Ethics: Provisions and Interpretative Statements for Emergency Nurses" at www.ena.org.

Question 6.
Several victims have arrived from a chemical plant after a bomb exploded. The victims are covered with a strong-smelling liquid and have labored respirations. Which of the following actions should the emergency nurse responding take first?
(a) Prioritize patients based on degree of respiratory distress
(b) Assess identity of chemicals the victims were exposed to
(c) Don personal protective garments 
(d) Remove the victims’ clothing
Answer:
(c) Don personal protective garments 

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

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

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

Question 8.
The signs and symptoms of critical incident stress can be physical, emotional, cognitive, or behavioral. Which of the following is a physical manifestation of this stress?
(a) Fatigue
(b) Confusion 
(c) Fear
(d) Anorexia
Answer:
(a) Fatigue

Rationale: 
Although all of the answers are manifestations of critical incident stress responses, the only one categorized as physical is fatigue.

According to the Occupational Safety and Health Administration (OSHA) Critical Incident Stress Debriefing (CISD) guidelines, the following critical incident stress manifestations often occur.

Physical	Cognitive	Emotional	Behavioral
Fatigue	Uncertainty	Grief	Inability to rest
Chills	Confusion	Fear	Withdrawal
Unusual thirst	Nightmares	Guilt	Antisocial behavior
Chest pain	Poor attention	Intense anger	Increased alcohol con­sumption
Headaches	Decreased decision­ making ability	Apprehen­sion and depression	Change in ^ communi­cations
Dizziness	Poor concentra­tion and memory	Irritability	Loss/in­crease in appetite
	Poor prob­lem-solving ability	Chronic anxiety

Question 9.
When communicating with someone whose primary language is other than English, it is important to do all of the following EXCEPT:
(a) Avoid slang, professional jargon, and acronyms.
(b) Have the patient rephrase what he thinks he heard you say.
(c) Pause to allow enough time for the patient to process what you said
(d) Simplify for him by asking more yes or no questions.
Answer:
(d) Simplify for him by asking more yes or no questions.

Rationale:
Asking more yes and no questions does not simplify the information for the patient. It is important to minimize the use of yes/no questions. Avoiding slang and jargon is important for any communication with patients. Pausing allows the patient to “translate”/comprehend what was just said, and asking the patient to rephrase is important for the nurse to see that the person understands the information given.

Question 10.
The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that a patient with no insurance:
(a) Should be transferred to a teaching hospital that receives federal funds.
(b) Must be transferred to a Level I trauma center as soon as possible.
(c) Should be transferred if the receiving hospital can provide additional care.
(d) Cannot be transferred to another facility, as defined by the COBRA law.
Answer:
(c) Should be transferred if the receiving hospital can provide additional care.

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

Question 11.
Which of the following is NOT a component of the transfer system between facilities?
(a) Communications with the receiving hospital 
(b) Following your hospital’s policies and procedures 
(c) Available transportation resources in the community
(d) Cost of the transfer to the appropriate location
Answer:
(d) Cost of the transfer to the appropriate location

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

Question 12.
Standards of Emergency Nursing Practice incorporate patient education as an expectation. Which of the following is NOT an expectation regarding this aspect?
(a) Most state nurse practice acts 
(b) Most state nurse practice acts 
(c) Quality assurance/quality improvement criteria
(d) Health Insurance Portability and Accountability Act (HIPAA)
Answer:
(d) Health Insurance Portability and Accountability Act (HIPAA)

Rationale: 
The Health Insurance Portability and Accountability Act (HIPAA) ensures the appropriate transfer of medical information and the protection of the patient’s privacy, not the patient’s education. Patient education is the responsibility of the emergency department nurse, especially upon discharge, and the need for patient education is recognized and stated in all other documents cited.

Question 13.
Teaching a patient with diabetes the symptoms of hyperglycemia and hypoglycemia is an example of which type of learning?
(a) Cognitive
(b) Affective
(c) Psychomotor
(d) Social
Answer:
(a) Cognitive

Rationale: 
Understanding of the signs and symptoms of a disease process utilizes cognitive learning skills. This type of learning requires thinking and reasoning in order to integrate the concepts. Affective learning involves feelings and attitudes. Psychomotor learning requires the coordination of the brain and extremities to complete a task. Social learning requires the ability to interact with others in a social setting.

Question 14.
Which of the following observations would indicate that a depressed patient is becoming suicidal?
(a) The patient slams the phone after speaking to a loved one.
(b) The patient refuses to eat a turkey sandwich.
(c) The patient refuses to eat a turkey sandwich.
(d) The patient refuses to eat a turkey sandwich.
Answer:
(d) The patient refuses to eat a turkey sandwich.

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

According to the Harvard University website, some suicides have absolutely no forewarning and are completely unpredictable. Many suicides and suicide attempts, however, do have warning signs.
A few behaviors that may put friends and family on notice that the risk of suicide is increased would be as follows:

• Talking about suicide: statements like “Yd be better off dead” or “If I see you again”
• Seeking the means: trying to get access to guns, pills, or other objects that could be used in a suicide attempt.
• No hope for the future: feelings of helplessness, hopelessness, and a feeling of being trapped (no way out), or believing that things will never get better.
• Self-loathing: feelings of worthlessness, guilt, shame, and self-hatred.    
• Getting affairs in order: giving away prized possessions or making arrangements for family members.
• Saying goodbye: unusual or unexpected visits or calls to family and friends, saying goodbye to people as if they will not be seen again.
• People who exhibit these signs often communicate their distress, hoping to get a response. This is very useful information that should not be ignored.
• National Suicide Prevention Lifeline at 800-273-TALK. Counselors are available 24 hours a day, 7 days a week. The service is available to anyone. All calls are confidential.

Question 15.
A registered nurse reads a journal’s research study. The study taught fever control measures to first-time parents. Which of the following is most important to determine before attempting to apply the same project in the nurse’s emergency department?
(a) Was the study approved by an Institutional Review Board (IRB)?
(b) What was the actual content that the researcher taught to the parents?
(c) Are the researcher’s and nurse’s settings similar enough for transferability?
(d) Did the researcher statistically verify the data results with an analysis of variance (ANOVA)?
Answer:
(c) Are the researcher’s and nurse’s settings similar enough for transferability?

Rationale: 

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

Question 16.
The Joint Commission in 2018 released a Quick Safety alert on “Identifying Human Trafficking Victims” and pinpointed several red flags of a potential victim. All of the following would be examples of human trafficking victims EXCEPT:
(a) Acting fearful, anxious, depressed, submissive, tense, nervous or paranoid, and avoiding eye contact.
(b) Requesting additional follow-up treatment at a separate appointment in order to see another provider.
(c) Showing reluctance or refusing to change into a gown and/or to cooperate with the physical examination.
(d) Exhibiting behavior or demeanor not in alignment with injury or complaint (that is, acts like it is “no big deal”).
Answer:
(b) Requesting additional follow-up treatment at a separate appointment in order to see another provider.

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

Question 17.
All of the following populations are commonly targeted for human trafficking EXCEPT:
(a) Native Americans, Native Hawaiians, and Pacific Islanders.
(b) Lesbian, gay, bisexual, transgender and questioning (LGBTQ) individuals.
(c) Employees involved in the foster care and juvenile justice system.
(d) Migrant workers, undocumented immigrants, and racial and ethnic minorities.
Answer:
(c) Employees involved in the foster care and juvenile justice system.

Rationale: 
The key word in this answer is “employees” because all of the other answers include populations commonly targeted. The children in foster care and juve- ; nile facilities are, in fact, also considered targeted popula-tions as well as members of all the other options.

Question 18.
Screening questions to identify human trafficking must be brief and limited because the perpetrator will not leave the victim alone for long. Simple screening questions include all of the following EXCEPT:
(a) “Are doors and windows locked so you cannot leave?”
(b) “Has your ID or documentation been taken from you?”
(c) “Have you been denied food, water, sleep, or medical care? ”
(d) “What is your cell phone number so we can reach you?”
Answer:
(d) “What is your cell phone number so we can reach you?”

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

• For more information on human trafficking, see The Joint Commission Resource entitled Quick Safety 42: Identifying human trafficking victims.
• “The United States is one of the largest markets and destinations for human trafficking victims in the world.1” and that "Knowing how to identify victims of human trafficking, when to involve law enforce¬ment, and what community resources are available to help the individual is important information for all health care professionals. 
• ” Identifying and helping victims of human trafficking can be difficult and can further endanger the victim. Most human trafficking victims or their families have been threatened with harm if the victim reveals their exploitation. In some cases, victims from different countries or cultures do not realize that their exploitation is unusual or criminal. 
• Also, some human trafficking victims have bonded with their exploiter, a condition called trauma bonding that is similar to Stockholm syndrome. Victims may keep silent about their exploitation from shame or fear of being humiliated. Since medical care is occasionally necessary for trafficking victims, healthcare professionals are in a unique position to help these unfortunate victims.

Question 19.
In 2018, The Joint Commission’s Quick Safety alert on “Identifying Human Trafficking Victims” stated all of the following EXCEPT:
(a) Human trafficking should only be addressed by the ED RN caring for the victim.
(b) Anyone working in a hospital or clinic should be trained to notice the red flags.
(c) Support staff such as transporters or technicians might seem less intimidating to victims.
(d) Medical care is often necessary for trafficking victims and we must be vigilant.
Answer:
(a) Human trafficking should only be addressed by the ED RN caring for the victim.

Rationale: 
RNs are important caregivers who should be trained to identify victims; however, ALL health care providers are able to assist and intervene with appropriate education. All of the other responses are appropriate.

Question 20.
The emergency nurse is triaging a patient who has a fear of leaving his house. He only comes outside when accompanied by his spouse. The nurse determines the patient is experiencing which of the following?
(a) Social phobia 
(b) Agoraphobia
(c) Claustrophobia 
(d) Hypochondriasis
Answer:
(b) Agoraphobia

Rationale: 
Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Patients fear a sense of helpless-ness or embarrassment and results in minimizing social and professional interactions. Social phobias include specific situations, such as the fear of speaking, perform-ing, or eating in public. Claustrophobia is a fear of dosed places. Hypochondriacs focus their anxiety on physical complaints and are hyper-focused on their own health.

Question 21.
Benzodiazepines such as lorazepam (Ativan) are no longer considered a first-line treatment for insomnia, agitation, and delirium in older adults. According to guidelines published in 2013, “elderly patients are significantly more sensitive to the sedative effects
of benzodiazepines. ” Emergency nurses know that benzodiazepines can cause which of the following?
(a) Respiratory depression 
(b) Hypoxemia
(c) Delirium
(d) Alcohol withdrawal
Answer:
(a) Respiratory depression 

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

Question 22.
Which level trauma center must have a trauma surgeon, trauma director, operating suite, and in-house operating room staff on duty 24 hours per day?
(a) Level I trauma center only
(b) Level I, IL and III trauma centers 
(c) Level I and II trauma centers 
(d) Level IV trauma center
Answer:
(c) Level I and II trauma centers 

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

Trauma Center Levels

• There are five different levels of trauma centers in the United States (this can vary by state—some states do not recognize all five levels). According to the American Trauma Society, the five levels are as follows:
• Level I provides total care, from prevention through rehabilitation. These also offer a teaching pro¬gram for medical residents, as well as for ongoing research.
• Level II is similar to a Level I trauma center but does not necessarily offer teaching or research. Both Levels I and II can treat either children or adults. Level III is smaller than Level I and II centers but can provide prompt care to injured patients.
• Level IV has demonstrated an ability to provide advanced  trauma life support (ATLS) before transfer of patients to a higher level trauma center. It provides evaluation, stabilization, and diagnostic capabilities for injured patients.
• Level V provides initial evaluation, stabilization, and diagnostic capabilities and prepares patients for transfer to higher levels of care.

Question 23.
A multisystem trauma victim is being transferred to a trauma center. The receiving physician insists that the patient be intubated before transfer. Who is legally responsible for ensuring that the patient is intubated before transfer?
(a) The receiving physician 
(b) The referring physician 
(c) The referring ED nurse 
(d) The transport team
Answer:
(b) The referring physician 

Rationale: 
The transferring hospital is legally respon¬sible for performing those treatment and diagnostic studies requested by the receiving facility. The referring physician is legally responsible for ensuring that tests and procedures are completed.

Question 24.
Before an air lift transfer, the emergency nurse recalls that air expands in the altitude of any aircraft; therefore, the nurse recalls issues related to gas-filled organs and medical equipment before transport. Which of the following is NOT an appropriate statement regarding this understanding?
(a) Air splints will expand and are encouraged.
(b) Chest tubes should be in place for pneumothoraces
(c) Decompress the stomach with a gastric tube.
(d) Insert a urinary catheter to monitor urinary ouifiut.
Answer:
(a) Air splints will expand and are encouraged

Rationale: 
Air splints are to be used with caution (if at all) and always loosened to accommodate the effects of alti-tude. The other responses are appropriate for air transport.

Question 25.
Increased emergency department patient length of stay (LOS) across hospitals in the United States increases risk for patients and leads to patient and staff frustration. Which of the following is NOT a way to improve throughput to avoid increased LOS?
(a) Timely testing and obtaining test results 
(b) Direct (or immediate) bedding whenever possible 
(c) Holding inpatients (boarding) in the ED
(d) Placing a provider at triage during peak hours
Answer:
(c) Holding inpatients (boarding) in the ED

Rationale: 
The longer a patient waits in the emergency department for a bed in an inpatient unit, the higher the potential exists for the patient to have an adverse event or poor health outcome. Obtaining specimens and test results in a timely manner, direct bedding when pos¬sible, and utilizing a provider in triage during peak times are all ways to help decrease both length of stay (LOS) and frustrations.

Emergency department (ED) boarders is another name for patients who have been admitted under an in-patient service but remain in the ED. The literature describes how ED boarders have worse outcomes than do their counterparts who are admit-ted quickly to inpatient beds. Some of the issues include increased medication delays, increased mor¬tality and morbidity, hospital expense, and overall hospital length of stay (LOS), as well as decreasing patient and staff satisfaction. In addition, the lit¬erature relates that ED boarders have a detrimental effect on other ED patients because ED nurses are caring for patients who would be better cared for by the expert nurses on their appropriate unit.

Question 26.
The American Nurses Association (ANA) defines bullying as “repeated, unwanted, harmful actions intended to humiliate, offend, and cause distress in the recipient.” Which of the following is a true statement regarding bullying?
(a) Some acts of aggression may be verbal and are entirely acceptable because of the stress of the ED. 
(b) ED nurses may not defend against violence because the perpetrator is <a patient or visitor.
(c) Bullying occurs in all work sectors, with the health care industry having much higher incidents.
(d) Bullying is less common than either sexual harassment or racial discrimination on the job.
Answer:
(c) Bullying occurs in all work sectors, with the health care industry having much higher incidents.

Rationale: 
Bullying has long been health care’s dirty little secret, with more incidents than in other work place venues. Acts of aggression may be verbal; however, they are NOT acceptable in the ED or in any other health care setting. ED nurses should defend against violence in the workplace no matter who the perpetrator is, and bullying is more common than sexual harassment and racial discrimination.

As described in The Joint Commission (TJC) safety issue brief 24 (June 2016): Civility is a system value that improves safety in health care settings. The link between civility, workplace safety and patient care is not a new concept. The 2004 Institute of Medicine report, “Keeping Patients Safe: Transforming the Work Environment of Nurses," emphasizes the impor¬tance of the work environment in which nurses provide care. Workplace incivility that is expressed as bullying behavior is at epidemic levels. A recent Occupational Safety and Health Administration (OSHA) report on workplace violence in health care highlights the magnitude of the problem. while 21 percent of registered nurses and nursing students reported being physically assaulted, over 50 percent were verbally abused (a category that included bullying) in a 12-month period. In addi¬tion, 12 percent of emergency nurses experienced physical violence, and 59 percent experienced ver¬bal abuse during a seven-day period.

Question 27.
An emergency nurse delegates the responsibility of taking and recording a patient’s blood pressure to the unlicensed assistive personnel (nurse’s aide). Later, the nurse notes that there is no blood pressure recorded on the patient’s chart. Which of the following options is the best response for this situation?
(a) Take the blood pressure now himself and speak to the UAP at the end of the shift.
(b) Talk to the involved unlicensed assistive personnel (nurse aide/technician) now.
(c) Ask the patient whether anyone took his blood pressure today.
(d) Discuss the matter with the charge nurse and proceed accordingly.
Answer:
(b) Talk to the involved unlicensed assistive personnel (nurse aide/technician) now.

Rationale: 
The unlicensed assistive personnel (UAP) may have taken the blood pressure and forgotten to chart it. Even if the task was not done, it is important to follow up to reinforce responsibility for the future. Taking the blood pressure himself may be duplication of work, and the matter should be cleared up now, not at the end of the shift. The patient could be mistaken about the blood pressure being taken if asked, and it still does not give the results even if it was done. More information should be clarified and the UAP dealt with directly before bringing in management. Management can be brought in if there is a repetitive pattern.

Remember!!! When the nurse is delegating tasks, the nurse is ultimately responsible for that task! The nurse should be providing follow through on all of the tasks that are asked of others to perform.

Question 28.
A patient in the triage area is yelling and becoming increasingly agitated; he throws his bottle of water on the floor. The family states this agitated and aggressive behavior is new over the past few hours. Which of the following is the best response for the triage nurse at this time?
(a) Approach the patient and directly confront him to control him through authority.
(b) Inform the patient that this is not acceptable behavior in the emergency department.
(c) Reassure the patient that the nurse is here to help him.
(d) Shout for security to call the police immediately.
Answer:
(c) Reassure the patient that the nurse is here to help him.

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

Question 29.
Which of the following is an advantage of ground transport over helicopter transport?
(a) Better radio communications with hospitals 
(b) More space inside 
(c) Faster speed 
(d) Fewer traffic and road factors
Answer:
(b) More space inside

Rationale: 
Ground vehicles have more space inside. However, helicopter transport has the advantages of having better radio communication with hospitals, traveling at faster speeds, and contending with fewer traffic and road factors.

Question 30.
A patient is pacing and agitated, with rapid speech and is becoming belligerent. Which of the following should be the first priority?
(a) Provide immediate safety for the patient.
(b) Offer the patient a less stimulated area to calm down.
(c) Change the subject by offering the patient food.
(d) Assist the staff in caring for the other patients’ safety.
Answer:
(a) Provide immediate safety for the patient.

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

Question 31.
A patient arrives in the emergency department with signs and symptoms consistent with a non-ST elevation myocardial infarction (NSTEMI). His vital signs are as follows: blood pressure, 100/68 mm Hg; pulse, 46 beats/minute, and respirations, 24 breaths/minute. The physician decides to transfer him to another facility ’by air. After stabilizing the patient with oxygen, an arterial line, intravenous line placement, and appropriate medication therapy, which of the following should be considered before transport via aircraft?
(a) Nothing; the patient is ready to be transported.
(b) The effect of air transport on the arterial line pressure bag
(c) The ability of the patient’s family to accompany the patient
(d) Ensuring that vital signs are documented just before departure
Answer:
(b) The effect of air transport on the arterial line pressure bag

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

Question 32.
When planning care for a patient in a crisis state, which of the following is a true statement?
(a) All individuals experiencing a crisis have the same crisis symptoms.
(b) Individuals in crisis state are displaying signs of severe mental illness.
(c) There is an underlying emotional illness exacerbating crisis state.
(d) There is an underlying emotional illness exacerbating crisis state.
Answer:
(d) There is an underlying emotional illness exacerbating crisis state.

Rationale: 
All individuals experiencing a crisis respond in their own way. There is no right or wrong response. People do not all respond the same and individuals in crisis do not necessarily have an underlying mental illness nor is there an underlying emotional illness that is exac-erbating the problem.

Question 33.
Quantitative studies are important in nursing research and utilize numeric findings for quantification. Which of the following is a true statement regarding quantitative studies?
(a) These studies compare the results of one form of treatment against a control group.
(b) This type of research gathers insight into a person’s motivations and opinions.
(c) This particular research study follows subjects with a particular disease process.
(d) This study examines relationships and determines the cause and effect of variables.
Answer:
(d) This study examines relationships and determines the cause and effect of variables.

Rationale: 

• Quantitative research (think QUANTITY) uses measurable data to formulate facts and uncover patterns; it examines the data to determine cause and effect. A study that compares treatments against a control group would be classified as a randomized control study in which participants are compared to a control group. Quantitative research does not necessarily follow all subjects of a specific disease process. Cohort studies follow patients over time and qualitative research (think QUALITY) utilizes small groups and individual insights to gather greater understanding of peoples’ opinions and motivations. It provides insights into the problem. QUALITATIVE studies can be used to develop ideas or hy-potheses for potential quantitative research.
• Case series and case reports consist of collections of reports on the treatment of individual patients or a report on a single patient. Because they are reports of cases and use no control groups to compare outcomes, they have little statistical validity.
• Case control studies are studies in which patients who already have a specific condition are compared with people who do not have the condition. The researcher looks back to identify factors or exposures that might be associated with the illness. They often rely on medical records and patient recall for data collection. These types of studies are often less reliable than randomized controlled trials and cohort studies because showing a statistical relationship does not mean than one factor necessarily caused the other.
• Cohort studies identify a group of patients who are already taking a particular treatment or have an exposure, follow them forward over time, and then compare their outcomes with a similar group that has not been affected by the treatment or exposure being studied. 
• Cohort studies are observational and not as reliable as randomized controlled studies, because the two groups may differ in ways other than in the variable study.
• Randomized controlled clinical trials are carefully planned experiments that introduce a treatment or exposure to study its effect on real patients. They include methodologies that reduce the potential for bias (randomization and blinding) and that allow for comparison between intervention groups and control (no intervention) groups. 
• A randomized controlled trial is a planned experiment and can provide sound evidence of cause and effect. Systematic reviews focus on a clinical topic and answer a specific question. An extensive literature search is conducted to identify studies with sound methodology. The studies are reviewed, assessed for quality, and the results summarized according to the predetermined criteria of the review question.
• A meta-analysis will thoroughly examine a number of valid studies on a topic and mathematically combine the results using accepted statistical methodology to report the results as if it were one large study. Cross-sectional studies describe the relationship between diseases and other factors at one point in time in a defined population. Cross-sectional studies lack any information on timing of exposure and outcome relationships and include only prevalent cases. They are often used for comparing diagnostic tests. 
• Studies that show the efficacy of a diagnostic test are also called prospective, blind comparison to a gold standard study.
• This is a controlled trial that looks at patients with varying degrees of an illness and administers both diagnostic tests the test under investigation and the “gold standard” test to all of the patients in the study group. The sensitivity and specificity of the new test are compared to that of the gold standard to determine potential usefulness.
• A retrospective cohort (or historical cohort) follows the same direction of inquiry as a cohort study. Subjects begin with the presence or absence of an exposure or risk factor and are followed up until the outcome of interest is observed. However, this study design uses information that has been collected in the past and kept in files or databases. Patients are identified for exposure or nonexposures and the data are followed forward to an effect or outcome of interest.
• Qualitative research answers a wide variety of questions related to human responses to actual or potential health problems. The purpose of qualitative research is to describe, explore, and explain the health-related phenomena being studied. 

Question 34.
The PICO acronym is often used in quantitative studies to help researchers ask focused clinical questions. The “P” in PICO refers to the “Population” or “Problem” being considered. What do the “I” and “C” represent?
(a) Intervention and Control group 
(b) Intervention aad Comparison
(c) Implementation and Considerations 
(d) Implementation and Considerations 
Answer:
(b) Intervention aad Comparison

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

• P: Population in the study/disease you are looking at (e.g., age, gender, ethnicity, with a certain disorder)
• I: Intervention or variable of interest (exposure to a disease, risk behavior, prognostic factor, new process)
• C: Comparison of who/what is measured “against” this group (could bet a placebo or “business as usual” as in no disease, absence of risk factor)
• O: Outcome: (risk of disease, accuracy of a diagnosis, rate of occurrence of adverse outcome)
• T: Time: The time it takes to demonstrate an outcome (i.e., the time it takes for the intervention to achieve an outcome or how long the pilot will be held)

Question 35.
The Health Insurance Portability and Accountability Act (HIPAA) includes protected information in public venues. However, protected health information can be shared without patient consent in which of the following situations?
(a) Insurance companies for billing purposes 
(b) To an ex-spouse for legal recovery of information 
(c) EMS to determine patient’s marital status
(d) To share with neighbors or friends who call
Answer:
(a) Insurance companies for billing purposes 

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

Question 36.
When caring for a case involving forensics, which of the following is an important concept?
(a) Cut off clothing through holes and stains.
(b) Place all clothing together in one neat pile.
(c) Package each piece of clothing in a plastic airtight bag.
(d) Use paper bags with tamper-resistant seal for evidence.
Answer:
(d) Use paper bags with tamper-resistant seal for evidence.

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

Evidence collection is an important aspect of emer¬gency nursing! Every nurse should understand the concept of "Chain of Evidence” as well as an understanding of basic forensics. At times the ED becomes the crime scene when the patient arrives.

Question 37.
An elderly patient with stroke-like symptoms has an active DNR (Do Not Resuscitate) order. In caring for this patient, the understanding would be which of the following options?
(a) Should not initiate labs or an IV line as the patient does not want further treatment
(b) May not provide care for this patient until family arrives and gives consent
(c) An intravenous line may be established, but no medications should be given.
(d) Should initiate care for this patient’s stroke symptoms regardless of the DNR wishes
Answer:
(d) Should initiate care for this patient’s stroke symptoms regardless of the DNR wishes

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

Question 38.
A research study involves asking a group of nurses questions regarding perception of the value of an ED- specific preceptor program versus a hospital-based preceptor program. This type of research is considered to be:
(a) Qualitative.
(b) Quantitative.
(c) Systematic.
(d) Retrospective.
Answer:
(a) Qualitative.

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

Qualitative studies basically report their findings with words and quantitative studies usually involve numbers. Think door to electrocardiogram time, and so on for quantitative studies.

Question 39.
A behavioral health patient is behaving bizarrely and is considered a danger to himself and others. His hold is based on which of the following types of consent? 
(a) Express consent
(b) Implied consent 
(c) Involuntary consent 
(d) Informed consent
Answer:
(c) Involuntary consent 

Rationale: 
This patient is considered involuntary be¬cause he no longer has the capacity to make decisions for himself. If the patient were not a danger to himself or others, this would be an example of informed consent. Implied consent occurs through the actions of conduct of the patient, as in coming to the ED seeking care or coop-erating with a procedur^. Express consent is expressed verbally or in writing. 

Question 40.
An 86-year-old patient is being prepared for surgery. Which of the following approaches best ensures he will understand the risks and benefits?
(a) Give him enough time to process the information
(b) Ask family members to make these decisions.
(c) Ask patient to respond immediately so he does not forget.
(d) Give the patient reading material to review postoperatively.
Answer:
(a) Give him enough time to process the information

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

Question 41.
An elderly patient has decided to discontinue treatment. It would be recognized that the patient is competent to make this decision and support the decision based on which of the following ethical principles?
(a) Justice 
(b) Fidelity
(c) Autonomy 
(d) Confidentiality
Answer:
(c) Autonomy 

Rationale: 
A patient is competent to make his/her own decisions and therefore entitled by the ethical principle of autonomy, the right to make decisions regarding a patient’s own body. Autonomy is the right of the patient to retain control over his or her body.

• Actions that attempt to persuade or coerce the patient into making a choice are violations of this principle, whether the medical provider believes these choices are in that patient’s best interest. 
• Beneficence refers to doing all that can be done to benefit the patient in each situation. All recommended procedures and treatments should consider each patient’s individual circumstances. Emergency staff members should be trained in the most current and best practices and must recognize that what is good for one patient will not necessarily benefit another.
• Nonmaleficence means “to do no harm.” This means that we must also consider whether other people or society could be harmed by a decision made, even if it is made for the benefit of an individual patient. Justice recognizes that there should be fairness in all our decisions, including equal distribution of scarce resources and new treatments.

Question 42.
Which of the following would the nurse avoid placing in the medical record when an error has occurred with a patient?
(a) Nurses involved in the care of this patient 
(b) Interventions that have been performed
(c) Physician notifications
(d) Incident report submitted
Answer:
(d) Incident report submitted

Rationale: 
Although it is important for the nurse to document this information in a variance or incident re-port, this is not to be documented in the patient medical record. The other answers should all be included in the patient record. Staff that are involved in the care of the patient, interventions performed, and physicians should always be included in all charting.

Please remember how important narrative charting is! Do not simply use checkmarks to denote all care of a patient. The nurse should be painting a picture with the written word, and it is imperative that a true "picture" of the patient and situation can be derived in cases of possible litigation. This is also true for nonlitiginous situations.

Question 43.
The common adage of being unable to show anger to someone at work, therefore you go home and “kick the cat” is a way to describe the defense mechanism known as:
(a) Displacement.
(b) Denial.
(c) Repression.
(d) Projection.
Answer:
(a) Displacement.

Rationale: 
Displacement is the defense mechanism illustrated by the adage “kicking the cat.” When the person is unable to confront the coworker who caused the issue, he/she might project that anger on a less threatening person or object. See the following CENsational Pearl of Wisdom! to learn more about the other types of defense mechanisms.

• Defense mechanisms are an unconscious protective measure that allows us to cope with unpleasant emotions. Some common ones include the following: Denial is when something is too difficult to handle, the person will "refuse to experience it. ” It is a way „ to protect oneself from facing and dealing with the unpleasant consequences and pain that accompany acceptance.
• Repression is similar to denial; however, repression involves completely forgetting the experience alto¬gether. The memory is buried in the subconscious, thereby preventing painful, disturbing, or dangerous thoughts from entering awareness. This is common with child abuse or other traumatic experiences that occurred early on in development.
• Displacement is the transfer of emotions from the per¬son who is the target of the frustration to someone or something else entirely. Subconsciously, the confronta¬tion is too risky, so the focus is shifted toward a target or situation that is less intimidating or dangerous. Projection occurs when insecurity about oneself causes to “project" feelings onto others; this is done because to recognize that particular quality in one self would cause pain and suffering.
• Regression is when a person will revert to an earlier level of development where the less demanding behaviors are a waf of protecting one from having to confront the actual situation.
• Rationalization occurs when a person will justify the bad behavior, often placing the blame on others or incidents that caused or provoked the behavior.

Question 44.
Which of the following would NOT be involved in the assessment of a patient’s motivation for learning?
(a) Patient’s verbal response to instructions 
(b) Patient’s nonverbal feedback
(c) Patient’s interest during teaching
(d) Patient’s education level
Answer:
(d) Patient’s education level

Rationale: 
The patient’s education level may affect how he learns, but not his motivation. Consideration of the behavioral, verbal, and nonverbal clues given by the pa-tient enables the nurse to accurately assess the patient’s motivation for learning.

Question 45.
Which of the following organizations provides a nationwide template to enable federal, state, local, and tribal governments to work together for a range of domestic incidents? 
(a) Federal Response Plan (FRP)
(b) Federal Bureau of Investigation (FBI)
(c) National Incident Management System (NIMS)
(d) Disaster Relief and Emergency Assistance Act
Answer:
(c) National Incident Management System (NIMS)

Rationale: 
NIMS integrates emergency preparedness and response into a national framework for incident management. The Federal Response Plan was created as a guide for an all-hazards approach to domestic incidents and how to group them. The Disaster Relief and Emergency Assistance Act was enacted as statutory authority for most federal disaster response activities and created the Federal Response Plan. The FBI is not involved in emergency preparedness.

Incident Command Structures are based on a three-organization system: incident command, mul¬tiagency coordination, and public information

Question 46.
Based on the relationship and time frame commonly available for patient education in the emergency department, which of the following kinds of learning goals are best established with a patient in this setting?
(a) Long term
(b) Short term
(c) Middle range
(d) Tertiary range
Answer:
(b) Short term

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

Question 47.
Which of the following is the best method for the emergency department staff to protect themselves against possible negligence or malpractice litigation?
(a) Document your actions with a difficult family member in the medical record.
(b) Document the nurse-to-patient ratio to defend your caseload.
(c) Provide and document care provided within accepted hospital standards.
(d) Provide the best care you can and describe what you were not able to complete as well.
Answer:
(c) Provide and document care provided within accepted hospital standards.

Rationale: 
Meeting and documenting the standards of care may not prevent litigation, but these actions will certainly provide support that the standards of care were known and adhered to. Actions should be documented for all patients, not just for difficult ones. Documentation of nurse-to-patient ratios does not relieve the nurse of the responsibility to provide care within ac¬cepted standards. Accepted practice is to document what was done for a patient, not what was not done.

Question 48.
What does the plaintiff have to prove in litigation for negligence?
(a) Intent to cause harm
(b) Substandard care delivery
(c) Mitigating circumstances
(d) Lack of intent
Answer:
(b) Substandard care delivery

Rationale: 
The plaintiff must prove that the care received was substandard. It is not necessary to prove intent to cause harm. Mitigating circumstances are issues that would be brought up by the defendant, not the plaintiff. Negligence is by definition an unintentional tort or a civil wrong done without intent by the defendant therefore, it is not necessary to demonstrate lack of intent.

Question 49.
Which of the following is the most common unintentional tort involving health care personnel?
(a) Malpractice
(b) Negligence
(c) Assault
(d) Battery
Answer:
(b) Negligence

Rationale: 
Negligence is the most common uninten-tional tort involving health care personnel. Negli-gence committed by a professional is malpractice, but not all malpractice is negligence. Malpractice is a more restricted, specialized kind of negligence, defined as a violation of professional duty to act with reasonable care and in good faith. Assault and battery are intentional torts.

Question 50.
Which of the following is a true statement regarding breach of duty?
(a) Willful violation of an oath or code of ethics regarding patient care
(b) Failure to meet accepted standards in providing care for a patient
(c) Threatening a patient with withholding pain medication
(d) Confining a patient to a psychiatric unit without a physician’s order
Answer:
(b) Failure to meet accepted standards in providing care for a patient

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

Question 51.
It is the plaintiff’s responsibility to prove certain elements in a negligence lawsuit. Which of the following is NOT one of these elements?
(a) A duty was owed to the patient.
(b) The defendant breached the duty.
(c) This breach of duty was the cause of the plaintiff’s injury.
(d) The plaintiff was at risk for an injury because of the breach of duty.
Answer:
(d) The plaintiff was at risk for an injury because of the breach of duty.

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

The requirements for'hiursing malpractice include the following elements:

• Duty: There must be a duty owed to the patient. For example, the patient is owed a safe environment, and a nurse has a duty to follow orders and care for the patient.
• Breach of duty: The specific duty owed to the pa¬tient has been breached, meaning that the duty has not been met. In terms of safe environment, the nurse forgets to put the bed rail up and the patient falls. The nurse’s failure to maintain the patient’s safe environment would constitute a breach of duty. Damages: The breach of duty must have caused injuries that result in damages. The injuries the patient suffered when falling out of bed are the damages that can be claimed. If the patient was not injured, there are no damages.
• Cause: This is generally the most difficult element to prove in a medical malpractice lawsuit. There must be a direct cause-and-effect link between the breach of duty and the injury. The breach of duty must have caused the injury. In the example, if the nurse had not left the bed railing down, the patient would not have fallen. The nurse’s breach of duty caused the injury.

Question 52.
“The protective privilege ends where the public peril begins” indicates the duty of the emergency nurse when a patient threatens another person    v
with bodily injury or harm. What does the quoted statement mean?
(a) Confidentiality between patient and nurse does not relieve staff of the duty to warn the threatened person and authorities.
(b) Confidentiality between nurse and patient is as sacred as the attorney-client privilege and is never broken.
(c) The emergency nurse must weigh the seriousness of the threat before breaking the confidentiality of that patient.
(d) Warning the patient not to commit a felony covers the emergency nurse as duty to warn and is sufficient.
Answer:
(a) Confidentiality between patient and nurse does not relieve staff of the duty to warn the threatened person and authorities.

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

Question 53.
With regard to the phrase “The protective privilege ends where the public peril begins,” which of the following patient situations would be subject to this quoted phrase?
(a) The discharge of a child with his parents to a new home
(b) The discharge of a single mother and her neonate
(c) The discharge of a psychiatric patient threatening to kill his wife
(d) The discharge of a woman with a gunshot wound to her apartment
Answer:
(c) The discharge of a psychiatric patient threatening to kill his wife

Rationale: 
Medical personnel have a duty to warn the intended victim (if known) and the authorities if there is potential for harm to others. Even though the medical personnel may not know who the victim might be, there is an obligation to tell the authorities about the condition of the patient. The other options do not pose a threat to anyone.

Question 54.
The discharge of a woman with a gunshot wound to her apartment
(a) Number of pregnancies and live births
(b) Date of last menstrual period
(c) Known sexual partners 
(d) Gynecologic health of her siblings
Answer:
(b) Date of last menstrual period

Rationale: 
The date of the last menstrual period provides information about the likelihood of a first-trimester pregnancy. This information may affect medications ordered and radiographic procedures performed. The number of pregnancies and live births is important information, but it has no impact on ordered medications or radiographic procedures. Information about known sexual partners is only important in the presence of a sexually transmitted infection. Sibling health history will not impact this situation.

Question 55.
A mother brings'her 3-year-old to the emergency department because of blood in the child’s underwear. The examination by the sexual assault nurse examiner (SANE nurse) reveals sexual assault and felonious penetration. The mother wants to leave. Which action should the nurse take?
(a) No action is necessary because the mother is the child’s legal guardian and her decisions are final.
(b) Immediately report the findings to Child Protective Services and the police.
(c) Encourage the mother to reconsider her decision and refer her to a child psychologist.
(d) Have the emergency department physician talk to the mother and try to persuade her to stay.
Answer:
(b) Immediately report the findings to Child Protective Services and the police.

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

Question 56.
Child Protective Services has decided to remove a child from the mother’s care pending further investigation of a sexual assault on the child. The mother becomes upset and is afraid the child’s father will beat her. The nurse can refer the mother to several social service agencies. Which one of the following agencies would be most appropriate in this situation?
(a) Local women’s shelter 
(b) The welfare bureau 
(c) A homeless shelter 
(d) A homeless shelter 
Answer:
(a) Local women’s shelter 

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

Question 57.
Which of the following is true regarding the Emergency Medical Treatment and Active Labor Act (EMTALA) mandate for a patient having labor contractions?
(a) If the contractions are 5 (or more) minutes apart, she should be referred to a hospital that offers maternity services.
(b) All patients having contractions must be medically screened and stabilized before transport to another facility.
(c) Only women in obvious active labor need to be medically screened before transport to another facility.
(d) The emergency department has the right to refuse patients when it does not offer the needed services.
Answer:
(b) All patients having contractions must be medically screened and stabilized before transport to another facility.

Rationale: 
All patients experiencing contractions must be medically screened before transport. Whether it is obvious that the patient is in labor or not, she must be medically screened and examined before the decision is made to transport to another facility. The emergency department does not have the right to refuse treatment to a patient before medically screening the patient.

Question 58.
Which of the following is a true statement regarding the Emergency Medical Treatment and Active Labor Act (EMTALA) mandate regarding a patient presenting without insurance?
(a) Medical screening examination cannot be delayed pending insurance coverage or the ability to pay.
(b) The patient must present proof of ability to pay before services are rendered. 
(c) Every hospital must maintain inpatient beds for patients who are not able to pay for services.
(d) The ability to pay for services should not be part of the admission procedure.
Answer:
(a) Medical screening examination cannot be delayed pending insurance coverage or the ability to pay.

Rationale: 
To ensure that patients are not denied care on the basis of their ability to pay, they must be medi¬cally screened and stabilized before their ability to pay is determined. Failure of a hospital to comply may result in denial of Medicare funding. Only hospitals accepting Medicare funding are inquired to have some beds available for the indigent. EVlTALA does not address payment for services as part of the admission procedure. It only addresses medical screening and stabilization of patients before transport or the determination of ability to pay for services rendered.

Question 59.
Several sources of law affect the emergency department nurse. Which source of law would Medicare laws fall under?
(a) Ordinances
(b) Common law 
(c) Constitutional law 
(d) Statutory law
Answer:
(d) Statutory law

Rationale: 
Statutory law is law made by federal and state legislatures. Medicare law is an example of a federal statute. Ordinances are laws passed by cities or local jurisdictions such as parking regulations. Common law is the body of law formed by judicial decisions in a courtroom setting. Constitutional law is the supreme law of the land.

The term “statute” simply refers to a law enacted by a legislative body of a government, whether federal or state. Federal laws (statutes) are enacted by the United States Congress and must be followed by every state in the country. The United States Constitution is the supreme law of the land. No federal or state law may violate it. However, federal laws do not cover all areas of the law, and that is when state (or local) laws will apply.

• Regulations: State executive agencies carry out state laws through the development and enforcement of regulations (also called rules or administrative laws) and have the effect of law. Someone violating a regulation is, in effect, violating the law that created it. Regulations are designed to increase flexibility and efficiency in the operation of laws. Most regulations are developed and enacted through a rule-making process, which includes public input. State agencies hold open meetings and public hearings, allowing citizens to participate in the creation of regulations.
• Ordinances: A state may delegate certain powers to other units of government within the state. County and municipal governments enact laws, often called ordinances, via specific powers granted to them by the state. County and municipal ordinances apply to everyone within the county or municipality limits. These ordinances may not violate state or federal laws.
• Common law: This is considered to be “judge made” law. It consists of the rules of law that come from the written decisions of judges who hear and decide litigation. Judges are empowered to make these decisions by the constitution and statutes. When a judge decides a case and publishes a written decision, the decision becomes the precedent for future litigation.

Question 60.
A 44-year-old patient with a broken right ankle refuses morphine for pain. The nurse notices that the patient continues to grimace after a cast has been applied. The patient still refuses the morphine, but the nurse decides the patient would obtain relief from the morphine and gives it intravenously, planning to tell the patient after she sees how well it worked. This is an example of which of the following?
(a) Assault
(b) Breach of duty
(c) Proximate cause
(d) Battery
Answer:
(d) Battery

Rationale: 
Battery is the nonconsensual, intentional, offensive touching of another person. Unlike assault, you do not have to warn the victim or make the victim fearful before you hurt for it to count as battery. If a nurse surprises the patient and pushes the patient from behind, that would qualify as battery. Assault and bat¬tery occur simultaneously when an individual threatens to harm someone and then physically harms that person.

Assault is the intention to cause harm with the ability to carry through with it. It involves making someone fear that you will cause harm. You do not have to actually harm someone to commit assault. Threatening verbally or pretending to hit are both examples of assault that can occur in the health care setting. A breach of duty occurs when care falls below the standards or is omitted. Proxi-mate cause is proof that a breach of duty caused injury to an individual.

Question 61.
A patient who slashed his wrist is placed on a suicidal hold and security is called to observe him, although the patient wants to leave the emergency department. Which of the following types of consent would allow staff to keep this patient and provide treatment?
(a) Implied
(b) Informed
(c) Involuntary
(d) Express
Answer:
(c) Involuntary

Rationale: 
Involuntary consent applies when an indi¬vidual refuses treatment but a physician, other official as authorized by law, or law enforcement issues orders for care to be provided for a designated period of time.
When an individual in a life- or limb-threatening situ¬ation is unable to provide consent, it is assumed that consent is present to save the limb or life; this is known as implied consent. Informed consent is obtained when a physician/provider has explained a procedure, risk, and alternate treatment options to a patient. Express consent is a voluntary consent for treatment from a competent person.

Question 62.
A patient took an overdose of Valium and requests that the incident not be reported because he could lose his job. It is a mandatory reportable situation. The physician states that he will not report it this time, but if it occurs again, he will. Which of the following options should the emergency nurse execute?
(a) Confront the physician as to whether he is reporting the incicjent.
(b) Assume the physician will report it because it is mandatory.
(c) Report the incident regardless of the physician’s promise to the patient.
(d) It is none of the nurse’s business; it is between the doctor and the patient.
Answer:
(c) Report the incident regardless of the physician’s promise to the patient.

Rationale: 
If the nurse recognizes that the incident is a mandatory reportable incident, even if the physician disagrees, it is the nurse’s responsibility to report it to the designated authority. The nurse shares equally with the physician in this legal responsibility.

Anytime the nurse feels uncomfortable about situations such as these, never hesitate to contact the charge nurse, department director, or administrative personnel on call.

Question 63.
Appropriate RN staffing in the emergency department requires that the nurse manager must;
(a) Know and utilize the patient volume and acuity levels by hour of the day and take into consideration variability by day of the week and/ or time of year.
(b) Be aware of The Joint Commission (TJC) standard that emergency services shall be appropriately integrated with other units and departments within the organization.
(c) Realize that patient visits in the emergency department are too unpredictable to appropriately staff on an everyday basis,
(d) For the sake of standardization, ensure that emergency department staffing is designed to mimic the rest of the organization.
Answer:
(a) Know and utilize the patient volume and acuity levels by hour of the day and take into consideration variability by day of the week and/ or time of year.

Rationale: 
Although exact volume and acuity levels can be somewhat unpredictable, the manager should track both over time so that numbers and type of staff are appropriately placed. Staffing patterns are unit specific and standardization is irrelevant. TJC’s standard for integrating emergency services is not directly related to the question.

ENA has a position statement on this aspect of care on its website under position statements at www.ena. org. Use position statements to help with issues that arise in emergency departments. They can help out¬line the issue and provide support for needed changes.

Question 64.
A team of nurses, physicians, and registration clerks meet to address a departmental goal of decreasing total length of stay (LOS) in the department. First, they collect and review data (sorted by triage category) on the length of time patients wait to be seen. This is an early step in:
(a) Descriptive qualitative research.
(b) Indicator relevance testing.
(c) Collaborative scientific research.
(d) Quality improvement process.
Answer:
(d) Quality improvement process.

Rationale: 
This situation describes a quality improvement process. This reflects an interdisciplinary approach to process improvement for better patient experience or outcome. It is not intended to generate or validate a sci-entific knowledge base such as research. The element of data collection is found in research also. In the research process, however, data collection occurs later (after a literature review and after decisions have been made re-garding conceptual or theoretical framework and research design). Indicator relevance testing is not a recognized entity in either process.

Question 65.
Which of the following factors should determine the composition of the intrahospital transport team?
(a) Patient’s acuity level
(b) Medications needed
(c) Patient’s weight
(d) Unit receiving the patient
Answer:
(a) Patient’s acuity level

Rationale: 
The patient’s needs for continuous monitoring, assessment, and interventions vary. The acuity level, complexity of care, and potential needs during the intrahospital transport will determine the combination of personnel needed on the transport team. The patient’s acuity will also dictate the treatment plan during the transport, which may include medications. The patient’s weight may add to the overall transport issues as far as manpower is concerned.

Question 66.
Brainstorming is a problem-solving method whereby a group rapidly generates which of the following types of solutions?
(a) As many as possible 
(b) As practical as possible 
(c) As wild and crazy as possible
(d) As high-quality as possible
Answer:
(a) As many as possible 

Rationale: 
Brainstorming is a problem-solving method that rapidly generates a large number of alternatives.'
Quality and practicality are unimportant. Some wild and crazy solutions emerge and make the process fun; such unconventional ideas help participants unleash their creativity.

Question 67.
Which of the following grade levels is usually the best for written discharge instructions?
(a) First
(b) Third 
(c) Fourth
(d) Fifth
Answer:
(d) Fifth

Rationale: 
The fifth and sixth grade levels are the best for written instructions. There is a formula that is applied to written papers to help decide which grade level it is written toward. This is called the FRY forftiula and takes into account length of words and syllables.

Question 68.
Which of the following is a manager allowed to do in response to a collective bargaining initiative?
(a) Prevent employees from engaging in recruiting activities during nonworking hours.
(b) Prevent employees from participating in informal union activities in patient care areas.
(c) Withhold desirable assignments from those nurses who are union organizers.
(d) Provide special considerations to discourage employees from joining the union.
Answer:
(b) Prevent employees from participating in informal union activities in patient care areas.

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

Question 69.
Which of the following would be an appropriate technique to employ to enhance recall for the patient receiving discharge instructions?
(a) Use a passive voice.
(b) Be general in explanations.
(c) Announce topics.
(d) Utilize medical terms.
Answer:
(c) Announce topics.

Rationale: 
Announcing topics helps the patient or family member focus on specific areas of the discharge instructions. For instance, announce the topic of new medications, then activity, and so on. An active voice, specific instructions, and short words or sentences, as well as no jargon is the better way to teach discharge instructions because they will assist with recall for the patient at a later time. Utilizing stories can also help and repetition can help embed the information into the pa-tient’s memory.

Question 70.
Many emergency departments have customer service committees whose charge is to improve customer relations. Effectiveness is most likely to occur in which of these scenarios?
(a) An all-nurse committee because nurses have the most patient contact
(b) A committee that includes all disciplines and levels of staff and management
(c) A small committee of manager? who can respond most effectively to complaints 
(d) A multidisciplinary staff-level committee that closely monitors complaints against staff
Answer:
(b) A committee that includes all disciplines and levels of staff and management

Rationale: 
Optimal customer service includes all staff, at all levels, in all disciplines. The committee works best when the problem is “owned” by those delivering service to customers as well as those in authority. An all-nurse committee places inappropriate emphasis on nursing. It is evident that nurses do have a great deal of patient contact and, therefore, opportunity to set a customer-friendly tone; however, there are countless factors that are not directly related to nursing, such as billing, medical diagnosis, and housekeeping. Waiting for complaints is passive, and an after-the-damage-is-done strategy, which is limited to monitoring and does not improve goals.

Question 71.
An applicant for an emergency department nursing position is qualified depending on personal qualities, education, experience, and credentials. An applicant’s (ENPC) (Emergency Nursing Pediatric Course),TNCC (Trauma Nursing Core Course), ACLS (Advanced Cardiac Life Support), and CEN (Certified Emergency Nurse) certification as well as RN (Registered Nurse) licensure are examples of which qualifications?
(a) Personal qualities
(b) Experience
(c) Educational preparation
(d) Credentials
Answer:
(b) Experience

Rationale: 
Certifications, courses, and licenses are con-sidered credentials. Experience is one’s work history. Educational preparation refers to degrees held as well as academic institutions and programs attended. Personal qualities are subjectively measured and include such things as perceptions of voice, dress, sense of humor, and energy level.

Question 72.
A department with a shared governance model would more likely have which of these scheduling processes?
(a) Self-scheduling of staff, by the staff 
(b) Management scheduling of staff
(c) Designated staif leader scheduling of staff 
(d) A centralized c'omputer-generated scheduling system
Answer:
(a) Self-scheduling of staff, by the staff 

Rationale: 
Self-scheduling is the option usually found in shared governance models, which emphasize staff accountability and involvement in operating a unit. Management scheduling, or having a designated staff leader for scheduling, places the work of schedule preparation directly on the manager (or designee); it deemphasizes staff maturity and responsibility. A central-ized system with computer-generated scheduling would provide little opportunity for staff input and is a poor fit with the decentralized approach underlying the shared governance model.

Question 73.
What is the purpose of research in emergency nursing?
(a) To enhance the professional status of emergency nursing
(b) To generate a scientific knowledge base for validating and improving practice 
(c) To evaluate new medical devices, tools, and medications
(d) To help nurses identify problems in their clinical setting
Answer:
(b) To generate a scientific knowledge base for validating and improving practice 

Rationale: 
The purpose of nursing research is to generate a scientific knowledge base for validating and improving practice. Although the professional status of emergency nursing may be incidentally enhanced by re-search, such enhancement is not the focus or goal. Iden-tification of new problems may be an outcome of nursing research, but most research depends on problem or ques-tion identification. Emergency nurses may have oppor-tunities to participate in medication studies and product evaluation programs, but neither represents the purpose of nursing research.

Question 74.
Research that aims to examine the feelings and perceptions of emergency nurses working with battered female patients is which of the following types of study?
(a) Qualitative
(b) Quasi-scientific 
(c) Quantitative
(d) Experimental
Answer:
(a) Qualitative

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

Question 75.
A registered nurse is the preceptor for a new graduate nurse. The graduate nurse tells the nurse preceptor that his patient has an order for a urinary catheter insertion but he does not know how to perform this procedure. Which of the following actions is best for the preceptor nurse?
(a) Refer him to the policy and procedure book.
(b) Do the procedure for him but require him to chart it.
(c) Tell him to call the clinical nurse educator.
(d) Perform the procedure with him. 
Answer:
(d) Perform the procedure with him. 

Rationale: 
The best choice in this situation is to help the new nurse by performing the procedure with him.
Doing the procedure for him or referring him to an outside resource (book or person) will not enhance the graduate nurse’s technical skills to fulfill this patient’s needs now. In addition, he may need assistance in physically locating the urethra (beyond a description). Documentation of a procedure should be done only by the nurse completing the procedure.