CEN Exam 1
A 30-year-old man comes to the emergency department with the acute onset of left flank pain radiating to the groin. Microscopic hematuria is present on urinalysis. What is the most likely diagnosis? a.ureteral calcium oxalate calculus b.ureteral cystine calculus c.testicular torsion d.cystitis
A: Ureteral calculi are a quite common cause of acute emergency evaluation, usually causing flank pain with radiation to the back and/or groin. About 75% of these are calcium oxalate or phosphate; less common are struvite, uric acid, or cystine calculi. While KUB or ultrasound may show the stone, helical CT is now the preferred diagnostic method. Additional workup includes CBC, chemistry panel, urinalysis, and straining of urine to catch a passed stone for chemical analysis. Nursing attention should be directed to intravenous hydration with input and output recording and narcotic or narcotic plus NSAID (e.g., ketorolac) administration for pain. Some patients may be discharged with analgesics and instructions for hydration and calculus capture. Testicular torsion is most common in adolescents and usually presents with testicular and groin pain with abdominal radiation; increasing pain by lifting the scrotum to the level of the pubic symphysis causes exacerbation of the pain (Prehn sign). Cystitis may be infectious or drug-induced, but cystitis usually causes dysuria and pyuria and shows positive urine cultures.
Which of the following is NOT recommended for routine hemodynamic monitoring of patients in shock? a.pulmonary artery catheter b.central venous pressure c.pulse oximetry d.superior vena cava oxygen saturation (ScvO2)
A: While observation of the patient's heart and respiratory rates, mental status, and adequacy of peripheral circulation are clinical indicators of shock, several invasive and noninvasive methods for following effectiveness of treatment are available. Pulse oximetry is a simple and noninvasive technique to measure peripheral oxygen saturation but is subject to limitations in estimating circulation and hypoxia, especially with use of vasoactive medications or hypothermia. Central venous pressure is a useful measure of circulating volume, cardiac performance, and vascular tone. Values under the normal range of 4 to 10 cm H2O indicate a low circulating volume while values above this range may indicate excessive fluid administration, pulmonary edema, or vascular obstruction. ScvO2 is measured from a catheter in the superior vena cava and a value of 70% is used to guide therapy even if clinical signs show improvement. Pulmonary artery catheters (e.g., Swan-Ganz) are not recommended for routine hemodynamic monitoring.
A 7-year-old child is brought to the emergency department after multiple bee stings about 30 minutes previously. He complains of itching, swollen lips, and difficulty breathing. Wheezing and stridor are heard. What is the most immediate treatment required? a.epinephrine 0.1 mg intramuscularly b.intravenous corticosteroid c.intravenous antihistamine d.broad-spectrum antibiotic
Answer: A The clinical picture of this patient is that of an anaphylactic reaction to bee stings which is potentially life-threatening. The onset of symptoms within 1 hour after exposure to the allergen is particularly worrisome as are the laryngeal and pulmonary signs. The airway must be established with intubation often necessary; high-flow oxygen, cardiac monitoring, and intravenous fluids are basics. Epinephrine given intramuscularly is the most rapidly acting agent and should be given as soon as possible after the diagnosis of anaphylaxis and every 5 to 15 minutes thereafter as needed. Steroids and antihistamines are slower acting than epinephrine but are often given to alleviate itching, angioedema, and hives. There is no indication for antibiotics in this clinical situation unless further signs and symptoms develop.
After an auto accident, x-rays of the patient's leg show a transverse fracture of the midfemur with several bone fragments surrounding the fracture site. The skin of the leg is intact. This type fracture is called: a.compression fracture b.comminuted fracture c.avulsion fracture d.open fracture
Answer: B A fracture is a break or disruption in a bone, generally divided into closed (no break in the skin) and open (protrusion of the bone through the skin). Fractures may take different anatomic patterns, depending on the bone location, the nature of the trauma and the bone density (may be diminished with osteoporosis). Compression fractures are most common in the spine in which a fracture of one or more vertebral bodies leads to a collapse of the spine at that location. An avulsion fracture reflects a forceful contraction of muscle mass, which pulls a bone fragment to break away at the tendon's insertion site. This type of fracture is often seen with severe joint strains. This patient has a comminuted fracture in which the trauma causes more than two separated portions of the bone. Often, several small bony fragments are seen at the site of the break.
Which statement best describes acute respiratory distress syndrome (ARDS)? a.ARDS is caused by trauma only. b.ARDS is sudden, progressive, and severe. c.ARDS is caused by an illness only. d.ARDS never results in lung scarring.
Answer: B ARDS is sudden, progressive, and severe, and can even lead to death.
An elderly female client presents to the ED with complaints of chest pain and a history of angina. After the initial triage, what would be the next appropriate interventions? a.cardiac monitor, oxygen, and sublingual nitroglycerin b.cardiac monitor, sublingual nitroglycerin, and Foley catheter c.cardiac monitor, IV, oxygen, and sublingual nitroglycerin d.oxygen, sublingual nitroglycerin, and Foley catheter
Answer: C A cardiac monitor, oxygen, and an IV should be in place for anyone complaining of chest pain and before administering nitroglycerin, especially in an elderly client, who may develop hypotension quickly. When a client does not respond to sublingual nitroglycerin, it indicates possible unstable angina and may require other interventions to relieve the pain.
A cancer patient is seen in the emergency department with high fevers and malaise for 2 days. She received chemotherapy about 10 days ago. Her physical exam is not revealing but her temperature is 103°F. A CBC shows a hemoglobin of 10 g/dL, WBC 4000 with 10% polys, 5% bands, 70% lymphs, 10% monos, and 5% other white or unidentified cells. Platelets are 60,000/mm3. Which of the following is NOT immediately appropriate? a.blood cultures from different sites b.electrolytes, liver and renal function tests c.eask if she has been receiving granulocyte colony-stimulating factor (G-CSF) d.white blood cell transfusion
Answer: D This patient has fever and neutropenia after chemotherapy. Neutropenia is defined as an absolute neutrophil count (ANC) under 1000/mm3, and a severe neutropenia less than 500/mm3 is particularly dangerous. These patients must be worked up quickly and antibiotic and possibly additional therapy started as soon as possible since the situation may be life-threatening. While myelosuppressive drugs differ in the length of time between administration and the nadir of the ANC, 10 to 14 days is typical. Multiple cultures from different possible sites of origin for sepsis must be done along with chest x-ray and other imaging as indicated by examination. Broad-spectrum antibiotics, such as ceftazidime or imipenem/cilastatin, should be started after cultures are obtained. She should be asked if she has been receiving G-CSF (Neupogen, Neulasta). WBC transfusions are rarely used today since they have a very short shelf life, do not last long in the circulation, and may cause allergic reactions.
Which factor is NOT a risk for heart disease but also should not be excluded when considering the diagnosis of MI when a client presents with chest pain? a. age greater than 65 b. nonsmoking female c. smoking any gender d. obesity
B: A nonsmoking female may not have any risk factors, but a female complaining of chest pain should be evaluated for an acute cardiac problem, like any client with risk factors. Females present with different symptoms when having an MI and may not have classic symptoms, and they may also have an MI without having risk factors. The other answers are all risk factors for cardiac disease and acute cardiac syndromes.
A 2-year-old is brought to the emergency department with mild fever, persistent restlessness, crying, and pulling his left ear. He has had a cold for about a week. Examination of the ear reveals a distorted light reflex and slight bulging of the tympanic membrane. What is the proper diagnosis and treatment? a.otitis externa and antibiotics b.otitis media and antibiotics c.otitis media and myringotomy d.acute labyrinthitis and antivertigo drug
B: Ear infections may cause severe and persistent pain, especially in children in the 6-month to 3-year age group and are a frequent cause of emergency department visits. Loss or distortion of the light reflex and bulging of the tympanic membrane are cardinal signs of otitis media, usually caused by bacteria such as Streptococcus Influenza or Haemophilus Influenza. Sinusitis and purulent rhinitis may accompany the otitis. Antibiotics to cover these organisms, topical warmed otic analgesics, and antipyretics are the usual treatment modalities. Otitis externa or swimmer's ear also causes otalgia and frequently follows swimming in contaminated water or a foreign body in the ear. Keeping the ear dry and using otic analgesics and antibiotics are indicated. Ear plugs while swimming or ear drying agents after swimming or showering are the usual preventive measures. Myringotomy is a surgical procedure to keep the middle ear draining in chronic otitis media and hopefully prevent such complications as mastoiditis, meningitis, ruptured tympanic membrane, or permanent hearing loss. Labyrinthitis is an infection of the inner ear and usually causes severe vertigo, most commonly in adults.
Which dysrhythmia would be identified on an ECG/EKG six-second strip by a heart rate of 76 and a PR interval of 0.24? a.sinus tachycardia b.first-degree atrioventricular block c.sinus bradycardia d.junctional escape rhythm
B: First-degree atrioventricular block is diagnosed partially by an EKG showing a PR interval of greater than 0.20 seconds.
The purpose of the primary assessment in any emergency is to a. perform a quick look-see to determine the illness or injury b. assess for life-threatening problems that require an immediate intervention c. make the client comfortable and remove wet clothing for the assessment d. gain a medical and surgical history, including allergies and medication
B: The primary assessment is done in a systematic way. Identifying a need and performing an intervention are essential before going on to the next step. Assess the airway and then intervene, assess the breathing and then intervene, and so on until you have performed a complete head-to-toe assessment to identify the immediate illness or injury and provided an immediate emergency intervention. Answer a is incorrect because it neglects the intervention aspect of the assessment. Answers c and d are incorrect because they are not aspects of the primary assessment.
A 75-year-old man has a history of several episodes of transient right-sided arm and hand weakness lasting an hour or two but with full recovery. He is diabetic and hypertensive and is taking medication for both conditions. This time the episode does not resolve and he is taken to the emergency department some 2 hours after the onset of symptoms. He is awake and able to answer questions and give a medical history. His chest is clear and no bruits are heard over the carotids. There is drift of the right arm on examination and his speech is slightly garbled. His blood pressure is 160/95 mm Hg and his pulse is irregular at 80 beats per minute. A CT of the brain reveals a small left-sided occlusion in a branch of the middle cerebral arterial circulation without hemorrhage. What should be the next step in his management? a.start nitroprusside to reduce his blood pressure to normal b.begin fibrinolytic therapy with alteplase (Activase) c.begin warfarin d.neurosurgical consultation for carotid endarterectomy
B: This patient had several transient ischemic attacks prior to his clear-cut signs of a stroke, shown to be nonhemorrhagic in nature. Such strokes may be caused by local thrombosis, especially in arteriosclerotic vessels, or by emboli arising in the carotid artery (usually at the bifurcation of the internal and external vessels) or the heart, most often in atrial fibrillation patients with clots in the atrial appendage. Because this patient arrived in the emergency department within 3 hours from the onset of symptoms, the current recommendation is to begin fibrinolytic therapy with recombinant tissue plasminogen activator (r-TPA). Some recent studies indicate benefit from this therapy may be achieved up to 4.5 hours after the onset of symptoms. Blood pressure management in stroke patients is tricky. Most would agree with slow reduction if the value is greater than 220 systolic or 120 diastolic or the stroke is hemorrhagic in nature. For patients treated with a fibrinolytic agent, significantly elevated blood pressure should be lowered to prevent reperfusion problems. If noninvasive carotid scanning shows marked stenosis, neurosurgical consultation for endarterectomy or angioplasty with stent placement is reasonable. Subsequent warfarin treatment may be appropriate if atrial fibrillation is present.
A chronically anemic patient is receiving a packed red blood cell (PRBC) transfusion. He suddenly develops fever and chills, tachypnea and dyspnea, and tightness in the chest. His urine flow is diminished and dark in color. What is the probable diagnosis and appropriate measures to take? a.air embolus; stop infusion, administer oxygen, and turn patient on left side b.hemolytic transfusion reaction; stop transfusion, send the untransfused blood and a patient blood sample to the blood bank, monitor urine flow and collect sample for the lab c.pyrogenic transfusion reaction; stop transfusion and switch to leukocyte-poor PRBCs d.circulatory overload; stop transfusion, consider diuretics
B: Transfusion reactions may be of several types and some of the symptoms may overlap. In nearly every case, the transfusion should be stopped immediately and the line kept open with normal saline or other maintenance fluid. This patient's symptoms and signs strongly suggest a hemolytic transfusion reaction due to ABO incompatibility. Type-specific blood that has been cross-matched is standard for blood and packed cell transfusions, but type O Rh negative (females and males) or type O Rh positive (males) may be given in severe emergencies. Hemolytic transfusion reactions are often severe and may be life-threatening so immediate supportive therapy is required. Pyrogenic reactions are mostly due to recipient antibodies to donor leukocytes and leukocyte-poor blood product is preferred. Air embolus is usually due to catheter manipulation (often by patient) or improper infusion technique. Circulatory overload, by overzealous or too-rapid transfusion, may produce symptoms of pulmonary edema; give diuretic and other appropriate treatment for this immediately.
Which factors about troponin levels are important to consider when caring for a client being evaluated for an acute myocardial infarction (MI)? a. The troponin level is not the most important factor when caring for a client with an acute MI. b. Troponin levels elevate 3 to 12 hours after MI onset. c. Troponin levels are specific to MI clients only. d. Troponin levels will elevate in unstable angina as well as in an MI.
B: Troponin levels are elevated 3 to 12 hours after an acute onset of MI. Answer a is incorrect because troponin levels have taken the place of enzymes as cardiac biomarkers. However, troponin levels can also elevate in other disease states, including renal failure, making answer c incorrect. Answer d is incorrect because troponin levels actually help to distinguish between unstable angina (UA) and MI. Troponin levels do not elevate in UA.
A forty-year-old female presents to the emergency department (ED) complaining of chest pain. After triaging the client, obtaining vital signs including a blood pressure of 90/46, and establishing an adequate airway, what is the next most important intervention for this client? a. registering the patient into the system b. ordering serum blood laboratory tests c. placing the client on a cardiac monitor, administering oxygen, and obtaining an electrocardiogram (EKG) d. giving a sublingual nitroglycerin tablet for the immediate relief of pain
C: A family member can register the patient into the system, blood tests must be done but can be done after the EKG, and, although nitroglycerin is an appropriate intervention for pain, the low blood pressure may need evaluation before choosing to give nitroglycerin. The appropriate intervention is to place the client on a cardiac monitor, give oxygen to decrease cardiac workload, and obtain an EKG to immediately evaluate the heart. The ED is a controlled setting where a physician should be readily available to look at the client, evaluate the cardiac monitor, and interpret the EKG to determine further interventions.
Which blood test may indicate infection or inflammation and would need to be used as part of the clinical picture with diagnosing and treating abdominal pain? a.white blood cell (WBC) count of 5.0 b.hematocrit (HCT) of 45 c.WBC count of 28.0 d.blood sugar (BS) of 74
C: An elevated WBC count would be indicative of infection or inflammation. The WBC count of 5.0 is normal. The HCT and BS levels listed would also be considered within normal limits.
Which of the following is NOT appropriate for screening for domestic violence by the emergency department nurse? a.asking if the person has been hit, kicked, or otherwise hurt by someone in the past year; if so, by whom b.asking, "Do you feel safe in your present relationship?" c.avoid asking about intimate person violence if the patient is in the emergency department for a medical ailment, not trauma d.asking if there is a partner from a previous relationship that makes the individual feel unsafe
C: Domestic violence, nearly always perpetrated against women, is a major problem confronted by the emergency nurse. Screening for possible cases should include answers A, B and D. Interestingly, victims of intimate partner violence often present with a medical ailment, not trauma. These include back, abdominal, or pelvic pain, headaches, urinary infections, sexually transmitted disease, or symptoms consistent with posttraumatic stress disorder (PTSD). Sometimes evidence of old trauma such as healing fractures or cosmetically concealed bruises may point toward the presence of domestic violence. Many victims will deny it but sometimes compassionate questioning in a private setting will elicit a positive response. The nurse may then offer advice, refer to a social agency or shelter, or ask for a consultation by the hospital social worker.
A patient presents with a history of nausea, vomiting, and diarrhea for several days after a Caribbean cruise. In the emergency department, she is weak, moderately hypotensive, and dehydrated. An ECG shows bradycardia, mild ST depression, and a U wave with some ventricular ectopic beats. What is the most likely electrolyte abnormality? a.hypomagnesemia b.hyperkalemia c.Hypokalemia d.hypocalcemia
C: Hypokalemia (potassium lower than 3.5 mEq/L) may result from gastrointestinal or renal loss, or from transfer from extracellular fluid to intracellular fluid. Drugs such as aldosterone, insulin, and beta2-agonists promote the latter. Gastrointestinal loss is the most likely cause in this patient and hypokalemia may be a feature of traveler's gastroenteritis. Renal loss occurs with diuretics or kidney disease and low potassium may be a feature of diabetic ketoacidosis or excess steroids. The ECG findings described are typical of low potassium but do not necessarily correlate with the degree. Potassium administration should be through a large bore or central venous catheter (it is locally irritating) by an infusion pump at 40 mEq/L not to exceed 10 to 20 mEq per hour. For severe hypokalemia, a 5 to 10 mEq bolus may be given but serial potassium and cardiac monitoring is required to avoid hyperkalemia, ventricular dysrhythmias, and death. Low serum magnesium levels may accompany hypokalemia and should be checked.
An elderly patient has recently taken a large dose of imipramine (Tofranil) in an apparent suicide attempt. He is confused and disoriented, hypotensive, and tachycardic with flushed skin and wide pupils. While being brought in by paramedics, he has a seizure. An ECG shows a sinus tachycardia with a prolonged QRS complex and QT-interval and T-wave abnormalities. Which of the following pharmacologic agents would NOT be appropriate? a.lorazepam (Ativan) b.sodium bicarbonate c.phenytoin (Dilantin) d.activated charcoal and sorbitol
C: Overdose of tricyclic antidepressants, often by elderly patients with suicidal intent, is less common now since the advent of SSRI drugs for depression but is still a fairly frequent medical emergency. More common is CNS dysfunction ranging from disorientation and confusion to seizures and frank coma; anticholinergic effects including flushed skin, dry mucous membranes, and mydriasis; and cardiac effects including conduction abnormalities and ventricular tachycardia. Phenytoin is contraindicated for seizures in these patients because it has sodium channel blocking activity and may worsen arrhythmias. The drugs are very well absorbed by activated charcoal; the combination of activated charcoal with sorbitol to overcome the anticholinergics effects on the bowel is useful. Sodium bicarbonate raises the blood pH and lowers the free drug concentration, improving some of the ECG abnormalities.
The emergency medical services (EMS) team transports an adult male with chest pain to the ED. They have initiated a large-bore intravenous (IV) line, administered oxygen, and placed the client on the cardiac monitor. Upon arrival to the ED, the initial EKG shows ST deviation in two leads, and the client is pale, clammy, and restless. What is the next intervention the ED nurse should anticipate? a. The nurse will give a report to the intensive care unit (ICU). b. The nurse will give a large dose of heparin. c. The nurse will prepare the client for the cardiac catheterization laboratory (cath lab). d. The nurse will order a repeat EKG for 8 hours in the future.
C: The goal for any suspected acute coronary syndrome is a time frame of ED door to cath lab or to balloon those arteries to be 90 minutes or less. ST segment deviation in two or more leads usually indicates an acute ischemic event, which requires an angiogram or angioplasty. The nurse may give a report and may order labs and repeat EKGs, but the immediate intervention is to get the client ready for the cardiac cath lab. This may require calling in a cardiac team, undressing the patient completely, and removing jewelry. It may also include any other orders a cardiologist requires for the patient before the procedure. An ED nurse should be prepared for the possibility of this invasive procedure.
The Emergency Medical Treatment and Active Labor Act (EMTALA) includes the following provisions EXCEPT: a.participating hospitals have emergency departments and receive funding from Health and Human Services (HHS) b.any patient who comes to the emergency department requesting examination or treatment must receive an appropriate medical screening exam to determine if an emergency situation exists c.to transfer an unstable patient, the receiving hospital must accept him or her and the transferring doctor must sign a form stating that the benefits of the transfer outweigh the risks d.verbal patient refusal of examination or treatment absolves the hospital from possible legal penalty
D: EMTALA was passed by Congress in 1986 as part of COBRA. Its intent was to prevent "patient dumping" and "economic triage" by hospitals participating in Medicare and receiving federal funds. It applies to all patients seeking emergency treatment whether they are Medicare patients or not. Triage refers to the order in which patients are seen by the physician, not whether or not they require medical examination. The patient must receive a medical screening exam before any disposition is made and the lack of insurance or out-of-plan HMO status is not a basis for transfer or discharge of the patient without medical examination. For unstable patients being transferred to another facility, the receiving hospital must accept the transfer and the emergency physician ordering the transfer must sign an approval note outlining the benefits and risks of the transfer. While a patient may refuse examination and treatment, simple verbal refusal may not be legally sufficient and every attempt should be made to obtain a written refusal, including a statement that the benefits and risks have been explained.
A patient is intubated and on mechanical ventilation. The ventilator alarm rings and the airway pressure is found to be elevated. Possible causes include the following EXCEPT: a.endotracheal tube obstruction with sputum b.pneumothorax c.bronchospasm d.cuff leak
D: Mechanical ventilation requires diligent observation of the patient and ventilator by the emergency nurse. Modern ventilators usually come with alarms that indicate high or low airway pressure. High pressure may be caused by endotracheal tube obstruction with sputum or kinks or inadvertent endobronchial displacement. The airway should be suctioned and tube placement checked. A chest x-ray is frequently helpful in determining the cause. Lung collapse, worsening of the underlying disease, and bronchospasm are also causes of elevated pressure. Leaks around the endotracheal tube cuffs will cause low airway pressure. Auto-positive end-expiratory pressure (auto-PEEP) is caused by premature inspiratory delivery before full expiration (as in asthma or COPD patients) and may lead to increased pressure and lung damage.
