CEN Chapter 6 Review

An appropriate intervention in the treatment of acute respiratory distress syndrome is: Mechanical Ventilation

ARDS, a severe pulmonary disorder that can be sudden or progressive, results in infiltrates, dyspnea, and hypoxemia. Decreased compliance of the lungs along with alveolar collapse can lead to severe hypoxemia; therefore, the initiation of mechanical ventilation will aid the patient in receiving adequate oxygenation. It is crucial to treat the underlying cause of ARDS; however, airway and breathing are always the first priority. Category: Respiratory Emergency/Respiratory Distress Syndrome

A normal full-term newborn has been delivered in the ED. The newborn is warmed, their temperature is being maintained, their airway is being suctioned, secretions have been cleared, and they have been stimulated. To evaluate the effectiveness of these interventions, the nurse anticipates the infant's preductal oxygen saturation target after 1 minute to be approximately: 63%

According to neonatal resuscitation, the preductal oxygen saturation target 1 minute after birth should be in the range of 60-65%. After the baby's initial cries and deep breaths, fluid moves out of the airways, causing the ductus arteriosus to contrict, and blood now flows from the right side of the heart into the lungs. It typically takes approximately 10 minutes for a normal full-term newborn to achieve oxygen saturation greater than 90%. According to neonatal resuscitation, the preductal oxygen saturation target 2 minutes after birth should be in the range of 65-70%. 3 minutes after birth, it should be in the range of 70-75%. 10 minutes after birth should be in the range of 85-95%. Category: GI, GU, Gyn, OB Emergencies/OB/Neonatal resuscitation

Which diagnostic finding is consistent with the presence of an esophageal injury? Widening of the mediastinum on chest radiograph.

Air from an esophageal injury leaks into the thoracic area, allowing air into the mediastinum; this results in widening of the mediastinum. Widened mediastinum may also be seen with aortic disruption and a pneumothorax. Esophageal tissue or matter may be visible in the chest tube. Patient with a possible ruptures esophagus should not have a nasogastric tube inserted because this can lead to further damage to the esophagus. The central venous pressure (CVP) would not be elevated in the presence of an esophageal injury. The CVP will be elevated in conjunction with a tension pneumothorax or cardiac tamponade. An echocardiogram is used to assess cardiac functions such as wall motion, valvular function, estimated cardiac output, and presence of pericardial fluid. It is not a diagnostic tool to assess for the presence of an esophageal injury. Category: Respiratory Emergencies/Trauma

A male presents to the emergency department with complaints of pain and swelling in his right groin area. The patient states the pain intensity has increased, and the swelling has become larger over the past several days. The emergency nurse should anticipate which diagnostic test to best identify the source of the patient's complaint. Abdominal ultrasound

An abdominal radiograph would be helpful in diagnosing a bowel obstruction but would not provide enough information to validate a diagnosis of inguinal hernia. A CT scan of the abdomen would be helpful to identify the source of the patient's discomfort in the absence of any physical signs. This patient has an obvious bulge in the inguinal area, so a CT would yield little additional information. An MRI might show the hernia, but the preferred method to diagnose a hernia is an ultrasound. The patient's symptoms are most likely a result of an inguinal hernia. The patient's physical exam usually is diagnostic, but an ultrasound can be performed to determine if strangulation or an intestinal obstruction is present. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical Emergencies/Gastrointestinal/Hernia

Ziprasidone (Geodon) is most appropriate for which of the following psychiatric scenarios? The adult patient: who is exhibiting acute manic behavior, is in handcuffs, and is being accompanied by the police.

Antimanic drugs are not appropriate in the treatment of depression. Diprasidone is classified as an antimanic drug that has a rapid onset of action. Category: Psychosocial and Medical emergencies/psychosocial/situational crisis

A patient arrives at the ED via EMS with sudden onset AMS. The patient was found wandering at the local bus station, is able to answer questions only after much thought, and is unable to recognize that they are currently in a hospital. The patient appears very anxious, is diaphoretic, and has uncontrolled tremors to bilateral arms. Which of the following diagnostic testing would be the first priority for the ED nurse to obtain in order to assist in proper diagnosis of this problem? Serum glucose

Any patient with an altered level of consciousness should have an immediate blood glucose level performed to rule out the presence of hypoglycemia. The patient is presenting with classic signs of hypoglycemia. Hypoglycemia is one of the most common causes of altered level of consciousness, and can be easily treated. Category: Psychosocial and Medical Emergencies/Medical/Endocrine conditions: glucose-related disorders

A homeless patient arrives in the ED by EMS after being found wandering on the street and talking to himself. The patient is in possession of proper identification but will not answer to their name. Speech is clear, and the patient shows no signs of aggressive behavior, but will not make eye contact with the ED nurse or follow simple commands. Which of the following signs and symptoms would alert the ED nurse to an organic cause for their psychosis? Signs of trauma

Any signs of trauma, including obvious fractures or contusions, would require further investigation to determine whether the patient's behavior has a psychiatric or an organic basis. Abnormal vital signs may indicate an organic cause of an altered mental response - for example, hypoxia or hypotension. Category: Psychosocial and medical emergencies/psychosocial/psychosis

A patient with a 2-year history of uncontrolled hypertension presents to the ED with a complaint of a severe headache. A computed tomography scan of teh head reveals the presence of a large subarachnoid hemorrhage. Which of the following is a LATE sign of increased intracranial pressure? Bradycardia

Apnea, not tachypnea, would be a late sign of increased intracranial pressure. Late signs of incranial pressure include the presence of Cushing's triad: bradycardia, widening pulse pressure, and apnea. In addition, late signs of intracranial pressure includes headaches, nausea/vomiting, changes in mental status, and behavioral change In addition, late signs of intracranial pressure may also include unresponsiveness, dilated nonreactive pupils, and posturing. Category: Neurological Emergencies/Stroke

The ED nurse is aware that the practice of lifelong learning is an essential element leading to the achievement of which of the following? Professional expertise

As evidenced in the nursing theory text "From Novice to Expert" by Patricia Benner, participation in lifelong learning is an essential element in the etransition from a novice to an expert professional. Depending on the spcific qualifications of the management position, a program of lifelong learning may or may not be a requirement. Lifelong learning can contribute to academic success; however lifelong learning often occurs outside the classroom with coaches or mentors who have no direct relation to an academic program. Category: Professional Issues/Nurse/Lifelong learning

A patient presents to the ED with frequency and urgency of urination, associated with the presence of right flank pain. On physical assessment, the patient exhibits a temperature of 102 and tenderness over the right costovertebral angle. Which of the following conditions is most consistent with the patient's signs and symptoms? Pyelonephritis

Bladder infection does have the symptoms of frequency, urgency, and burning on urination, but a bladder infection is not usually associated with fever and tenderness over the costovertebral angle. The costovertebral angle is located at the angle made by the vertebral column and the costal margin. When the affected side is percussed over the costovertebral angle, the patient with pyelonephritis will report pain. Category: GI, GU, Gyn, and OB Emergencies/GI/Infection

On review of a patient's current medications, the ED nurse identifies the patient has been prescribed an alternative drug for depression. Which of the following is an alternative medication used in the treatment of depression? Bupropion (Wellbutrin)

Bupropion is considered an alternative drug for treatment of depression. It may also be used to treat ADHD or to help people quit smoking by decreasing cravings and the effects of nicotine withdrawal. The medication may be used to prevent autumn-winter seasonal depression. It may also be used with other medications to treat bipolar disorder (depressive phase) and to treat anxiety in people with depression. It is not considered an atypical treatment or frontline drug for depression. Category: Psychosocial and Medical Emergencies/Psychosocial/Depression

The ED nurse is participating in the care of an obtunded patient presumed to have taken an overdose of a tricyclic antidepressant. The patient has a palpable pulse, and an ECG is obtained. The nurse would anticipate the presenc of which ECG finding? Sinus tachycardia with both a widened QRS interval and prolonged QT interval.

Cyclic antidepressants typically cause a tachycardia with prolonged QRS and QT intervals. Although delayed or inappropriate intervention in the setting of cyclic antidepressant overdose may result in cardiopulmonary arrest and ventricular fibrillation, this patient currently has a pulse, and this dysrhythmias would not be anticipated at this time. Category: Cardiovascular emergencies/dysrhthmias

A tube thoracostomy has been placed for a patient with a hemothorax. Initially after placement, what output amount would alert the nurse to anticipate that the patient would be taken to the OR for an emergency thoracotomy? 1000 mL

If there is at least 1000 mL of blood in the chest initially or blood drainage greater than 200 mL per hour for 3-4 hours, then an emergency thoracotomy may be considered to identify and repair the bleeding source. Category: Respiratory Emergencies/Trauma

What is the priority assessment for a patient who has sustained a traumatic laceration to the upper arm? The presence of a distal or radial pulse

Lack of distal pulse indicates vascular compromise to the arm and requires immediate intervention to preserve limb function. Category: Maxillofacial, Ocular, Ortho, and Wound Emergencies/Wound/Lacerations

A patient who recently returned from a trip to East Africa presents to triage complaining of fever, abdominal pain, bloody diarrhea, and weakness. The triage nurse recognizes that this patient is most at risk for which of the following? Ebola virus

Fever, abd pain, weakness, muscle pain, diarrhea, fatigue, vomiting, and unexplained hemorrhage and bruising with known recent travel to East Africa put this patient most at risk for having the Ebola virus. Category: Professional Isusues/System/Symptom Surveillance: Recognizing symptom clusters

A non-English-speaking patient presents to the triage nurse. The best method for the emergency triage nurse to effectively communicate with the patient is to use which of the following? A certified translator fluent in the patient's native language.

Fluency in a language does not guarantee that an individual is a qualified interpreter. A certified interpreter or designated interpretation service is a better alternative. Using a family member or friend of the patient to provide services would be a violation of the patient's right to privacy. The use of an illustrated chart may be helpful in some situations, however the use of illustrations alone does not comply with Title VI of the Civil Rights Act. Title VI of the Civil Rights Act requires interpreter services for all patients with limited English proficiency. The patient must be afforded the ability to ask questions and understand the answers to their questions and participate in their plan of care. Category: Professional Issues/Patient/Cultural Considerations

There are four classifications of radiation particles that can affect life: alpha, beta, gamma, and neutrons. Of these four, which one is able to penetrate the most objects (paper, wood, concrete) and is therefore more dangerous to life? Neutrons

Gamma radiation can be absorbed by paper and wood but cannot be absorbed by concrete. Beta particles can be absorbed by paper, not by wood or concrete. Neutrons can be absorbed by all three objects and is therefore more dangerous to life. Category: Environment and Toxicology Emergencies, and Communicable Diseases/Environment/Radiation Exposure

A 3-week-old infant presents to the ED with a temp of 100.9 F. The infant has a normal physical exam, normal chest radiograph, and WBC of 15,000 and appears sleepy. The ED provider decides to perform a lumbar puncture. What disease process can be confirmed by this procedure? Meningitis

Group B strep is the most common cause of meningitis in newborns. Meningitis is the result of the inflammation of the meninges. The mortality can be as high as 56%. The use of LP in suspected subarachnoid hemorrhage can lead to herniation of the brain stem in the presence of increased ICP, and patient death. Category (Pediatric): Neurological emergencies/meningitis

The National Incident Management System requires that hospitals have plans and procedures in place to be prepared for emergency management situations, such as mass casualty incidents and disasters. One system that helps hospitals be prepared and creates a command structure is the: Hospital Incident Command System

HICS is the hospital command structure that is used within hospitals to plan, prepare, and implement a command structure for disasters and mass casualty incidents. Category: Professional Issues/System/Disaster Management

A patient presents to the emergency department with complaints of upper abdominal fullness, fatigue, and nausea for the past 2 weeks. When obtaining the patient's history, the triage nurse would be most concerned that the patient may have developed hepatitis A if the patient reports having recently traveled overseas to assist in the clean-up activities in a town flooded by heavy rains.

Hepatitis A is transmitted by the fecal-oral route, sharing used IV needles will not transmit the hep A virus. Hep A is prevalent in areas of poor sanitation. Category: GI, GU, Gyn, OB emergencies/GI/Hepatitis

The ED nurse is reviewing the medication orders for a patient newly diagnosed with a subarachnoid hemorrhage. Which of the following orders would cause the ED nurse to question the provider? Dexamethasone 16mg daily

High-dose corticosteroids are not recommended for patients with an acute SAH. Some studies have shown that the administration of a statin will help to increase cerebral blood flow and reduce vasospasm in patients with an acute SAH. Category: Neurological Emergen ies/Stroke

IV nitroprusside (Nipride) has been ordered for BP reduction in a pt with a hypertensive emergency. The pt's BP is 280/124 with a MAP of 176. When titrating the Nipride for this patient, which order has the safest parameter to follow? Titrate Nipride to a MAP of 132 over the next hour

Hypertensive emergency is defined as severe htn with signs or symptoms of end organ dysfunction. It is recommended that the patient's MAP be reduced by about 20-25% within the first hour of treatment, and rapid reduction of BP should be avoided to prevent organ hypoperfusion. Category: Cardiovascular Emergencies/Hypertension

A patient complains of transient palpitations and occasional numbness and tingling of their fingers and nose. While vital signs are being obtained, the ED nurse observes a sudden onset of carpal spasms on the arm on which the blood pressure cuff is being inflated. The nurse recognizes that this finding is consistent with the presence of: hypocalcemia

Hypocalcemia results in excitation of the nervous system, including tetanic contractions of skeletal muscle. This response is referred to as Trousseau's sign. Hypercalcemia generally presents with muscle weakness and depressed deep tendon reflexes. This particular response is not related to hypokalemia. Hypokalemia may present with hyporeflexia. Hyperkalemia may present with muscle weakness and flaccid paralysis. Category: Psychosocial and Medical Emergencies/Medical/Electrolyte/fluid imbalance

A patient with severe respiratory distress has been intubated, and mechanical ventilation has been initiated. The ventilator is alarming, indicating high airway pressures. As the emergency nurse, you are aware that this alarm indicates the importance to assess for the: presence of secretions.

If, after suctioning the ET tube, the ventilator continues to give high-pressure alarms, you should look for signs of pneumothroax (subcutaneous emphysema, absent/decreased breath sounds over the affected side, asymmetrical chest movement, tracheal deviation), but only after the airway has been assessed and cleared. The patient may need additional sedation to tolerate endotracheal intubation. High pressure alarms can be caused by coughing, gagging, secretions, ventilator asynchrony, kinked tubing, and tubing condensation. Category: Respiratory Emergencies/Obstruction

Which is the term used to describe a form of shock that occurs following a large pulmonary embolism that has resulted in unstable patient hemodynamics with decreased tissue perfusion? Obstructive shock

In obstructive shock, cardiac output and tissue perfusion are inadequate because of an obstruction limiting venous return to the heart during diastole. A large pulmonary embolism would create such an obstruction. Category: Respiratory Emergencies/Pulmonary Embolus

A patient presents to the ED voicing thoughts of suicidal ideation. Why is it important to identify and address medical issues before treating the mental health issue? Medical problems can mimic mental health problems.

It is important to rule out potential medical problems that may be life threatening and require immediate correction or patient stabilization. Medical problems can cause behavioral issues and can mimic mental health problems. They may be caused by existing medical health problems. Category: Psychosocial and Medical Emergencies/Psychosocial/Suicidal Ideation

The assessment of a patient involved in a MVC reveals muffled heart sounds and distended neck veins. The nurse understands that the treatment for this life-threatening situation is to: Prepare for a 3- to 4-cm incision to the left of the xiphoid process

Minimizing the administration of IV fluids in addition to possible intubation and ventilation support is the treatment for cardiac contusion but is not the immediate treatment for pericardial tamponade. Muffled heart sounds and distended neck veins are classic signs of pericardial tamponade. A 3- to 4-cm incision to the left of the xiphoid process allows for pericardial decompression or release of pericardial tamponade, which is the treatment for this life-threatening situation. Category: Cardiovascular emergencies/pericardial tamponade

A patient presents to the emergency department stating they were hunting the previous day in a heavily wooded area. This morning the patient noticed a red, itchy rash with many blisters covering their face, back, neck, and arms. The emergency provider diagnoses the patient with poison ivy. What medication should the emergency nurse anticipate will be prescribed for this patient? An oral corticosteroid

Narcotic pain medications are typically not prescribed in the treatment of poison ivy and may increase the itching the patient is experiencing. Acetaminophen or ibuprofen should be sufficient for the control of any discomfort the patient is experiencing. There are no signs of a bacterial infection at this time, so an antibiotic is not indicated. An antifungal agent would not be the appropriate treatment for poison ivy exposure. The patient's rash is widespread, so it is likely that they will be prescribed an oral corticosteroid such as prednisone. Category: Psychosocial and Medical Emergencies/Medical/Allergic reactions and anaphylaxis

Which of the following patients would benefit from the administration of nimodipine (Nimotop) to decrease the risk of associated cerebral infarction. A subarachnoid hemorrhage resulting from a cerebral aneurysm

Nimodipine is a calcium channel blocker proved to improve outcomes in patients with nontraumatic subarachnoid hemorrhage by decreasing cerebral vasospasm and decreasing the incidence of cerebral infarction. This drug is not indicated, and shows no benefit, in traumatic subarachnoid hemorrhage or subdural hematoma, regardless of the cause. Category: Neurological Emergencies/Stroke

A patient presents to the ED after being splashed in both eyes with a cleaning solution. During assessment, the ED nurse notes the presence of bilateral corneal clouding and prepares to irrigate the eyes. The ED nurse knows the irrigation may be discontinued when: the ocular pH reaches 7.0 in each eye.

Normal ocular pH is 7.0-7.3. Irrigation is performed until the ocular pH is within normal range. Relief of pain is not a determining factor in discontinuation of irrigation. Volume of the irrigation solution is not a determining factor in discontinuation of irrigation. Category: Maxillofacial, ocular, ortho, and Wound Emergencies/Ocular/Burns

An elderly patient presents to the ED c/o a severe boring type of pain in the right eye. The patient reports nausea, seeing halos around objects, an the presence of a headache behind the right eye. The patient has been diagnosed with acute angle-closure glaucoma and has received both 500 mg of acetazolamide (Diamox) intravenously and a 500 mg dose orally. Timolol (Timoptic) was instilled topically into the right eye. The emergency nurse identifies that this therapy has been effective when which of the following occurs? The patient's IOP is 20 mm Hg.

Normally IOP is 12-22 and eye pressure of greater than 22 is considered higher than normal. Acute angle-closure is defined as at least two of the following symptoms: ocular pain, nausea/vomiting, and a history of intermittent blurring of vision with halos; at least three of the following signs: IOP greater than 22, conjunctival injection, corneal epithelial edema, mid-dilated nonreactive pupil, and shallower chamber in the presence of occlusion. Acetazolamide and topical beta blockers are administered to decrease IOP. Antiemetics should be administered because vomiting increases IOP.

When caring for an elderly patient with dementia, the emergency nurse is aware that a patient with dementia will directly exhibit which of the following first? Impaired Communication

The dementia patient will first require additional time to promote communication. Patients with dementia frequently cannot recall their past medical history, medications, and recent visits to providers. Thus, the medical history may be incomplete, and this increases the risk for medical error in this population. The fast-paced and overwhelming ER environment increases confusion and distraction, impairs communication, and increases the risk of disruptive behaviors. This is the rationale that supports separate, quieter environments for the geriatric population. In the busy, rapidly changing, noisy atmosphere of the ED, patients with dementia are easily distracted, and communication becomes difficult. Category: Neurological Emergencies/Alzheimer's disease/dementia

The presence of a suspected testicular torsion is best evaluated using which diagnostic study? Doppler sonography

The twisting of the testicle results in the strangulation of the blood supply to the testis. A CT scan cannot determine adequacy of blood flow. The diagnosis of testicular torsion is made by clinical findings and doppler sonography, which will demonstrate a lack of blood flow to the affected testicle. Testicular torsion most commonly results from a congential abnormality of the testicle. Category: GI, GU, Gyn, and OB Emergencies/GU, Testicular torsion

The provider is considering the administration of alteplase to an 82-year-old patient diagnosed with an acute ischemic stroke. In addition to the patient's age, which other factor would exclude the patient from the administration of alteplase within the recommended extended 3-4.5 hour time window? Hx of Diabetes

There is no upper limit within the NIHSS for the administration of alteplase. A hx of ST-elevation MI does not include the patient from receiving alteplase. The exclusion criteria include both age greater than 80 years AND a hx of diabetes and/or a prior stroke. Category: Neurological emergencies/stroke

To be compliant with the US Emergency Medical Treatment and Active Labor Act, all patients presenting to the ED must have had which of the following performed? Medical screening exam

Triage is not a medical screening exam. Triage assessment and assignment of an acuity rating do not fulfill the legal requirement of the patient receiving an MSE. An MSE is performed by a physician or physician extender as identified by the hospital bylaws. One set of vitals would be a component of an MSE but does not entail the complete MSE process. Category: Professional Issues/System/Federal regulations

Following a MVC, a patieint arrives in the emergency department with a suspected blunt abdominal injury. VS are BP 100/72, HR 106, RR 18, T 36.2 C. The ED nurse should anticipate which of the following to be performed as part of the patient's initial assessment? Focused assessment with sonography for trauma exam (FAST exam)

A CT scan should only be indicated for the hemodynamically stable patient. Although it is useful in determining the management of nonoperative solid organ injuries, a CT scan is not useful in identifying injuries to the diaphragm or GI tyact. Hemoglobin and hematocrit will not reflect recent hemorrhage and should only be used as a baseline to compare future levels, especially if the patient needs surgery. A FAST exam is quick accurate, and noninvasive bedside assessment tool that provides a rapid evaluation of the peritoneum and is recommended by the American College of Surgeons for the initial assessment of the patient with blunt abdominal trauma. Diagnostic peritoneal lavage is an invasive procedure reserved for the hemodynamically unstable patient. VS for this patient do not suggest hemodynamic instability, so a FAST exam is appropriate. Category: GI, GU, Gyn, OB Emergencies/GI/Trauma

The emergency nurse anticipates heparin to be administered for the treatment of DIC in which of the following situations. Excessive fibrin that has caused digital ischemia.

A patient with DIC that results in excessive bleeding regardless of the cause would not benefit from the use of heparin because of the continued increased risk of bleeding. A patient with DIC and excessive fibrin that has caused acral cyanosis and ischemia in the digits may benefit from the administration of heparin. Category: Psychosocial and Medical Emergencies/Medical/Disseminated Intravascular Coagulation (DIC)

A 5-year-old patient presents to a general emergency department. The patient requires a dose of oral medication for the illness. The nurse understands that this patient is at increased risk for medications errors because of which of the following? Weight-based dosing

A patient's inability to swallow is of concern, and precautions or a change in the route of administration should be considered. However, the primary cause for medication errors in children is the failure to administer medications per weight-based dosing. For medications to be administered in the appropriate dose, the child's weight must be obtained and the medication dose properly calculated. Children pose a risk for emergency care because most emergency departments are built around adult needs. Children are at increased risk of medication errors because of weight-based dosing, medicine dilution, and the inability to communicate their needs or responses. Category: Professional Issues/Patient/Patient Safety

Which wound is the highest risk for development of osteomyelitis? Deep puncture wound in the foot from stepping on a nail

A puncture wound of the foot is associated with deep penetration resulting from weight bearing on a sharp object with frequent penetration of a metatarsal bone. The patient will complain of pain, redness, and swelling within 4-7 days following injury as the infection begins to develop. Category: Maxillofacial, Ocular, Ortho, and Wound Emergencies/Wound/Puncture wounds

A young mother presents to triage with her toddler, stating the child fell while walking and now will not move their left arm. However, the child fell on her right side. What should the emergency triage nurse do next? Ask the mother if she attempted to prevent the child from falling by holding onto the opposite arm.

A radiograph study is frequently unwarranted in radial subluxation. The diagnosis of radial subluxation can be made by physical examination. The subluxation can be easily relocated with good return of function. It is not necessary to immobilize the extremity following relocation of the subluxation. Subluxation is partial joint disruption (partial dislocation) that maintains some contact with the articulating surfaces. In children under the age of 5, radial head subluxation is present in approximately 20% of upper extremity injuries. If a radial head subluxation is present, the patient reduction of the partial dislocation should be performed by the ER provider. It is not within the scope of practice for an ER nurse. Category (Pediatric): Maxillofacial, Ocular, Orthopedic, and Wound Emergencies/Ortho/Fractures/Dislocations

The ED nurse is caring for a patient who was ffound lying on the floor for two days, unable to get up following a fall. The patient's skin assessment reveals an area of purple discoloration along the patient's greater trochanter, which is boggy and warm to the touch. The ED nurse recognizes this wound as a potential deep tissue injury.

A stage 1 pressure ulcer is described as intact skin with nonblanchable redness of a localized area, usually over a bony prominence. This is inconsistent with a wound that is boggy and warm to the touch. A bruise is the exravasation of blood in the tissues as a result of blunt force impact to the body. This is not the most accurate description relating to the etiology of this wound. A deep tissue injury is described as a purple or maroon localized area or discolored intact skin or blood-filled blister resulting from damage of underlying soft tissue from pressure and/or shear. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface, which is consist with the patient's history of lying on the floor for 2 days. A stage 4 pressure ulcer is described as full thickness tissue loss with exposed bone, tendon, or muscle. Cateogory: Maxillofacial, ocular, ortho, and wound emergencies/wound/trauma

Which assessment finding would best indicate that chest tube insertion has been successful in relieving a tension pneumothorax? Improvement in hemodynamics

A tension pneumothorax is a life-threatening emergency that occurs when air enters the pleural space during inspiration and is unable to escape during exhalation. The patient may still have discomfort related to chest tube placement and underlying injuries. The improvement of hemodynamics is the best way to assess the success of relieving a tension pneumothorax. The increasing intrathoracic pressure compresses the lungs, heart, and great vessels, resulting in markedly decreased cardiac output. Noted signs and symptoms include severe respiratory distress, tachycardia, hypotension, and poor tissue perfusion.

A patient arrives complaining of a sudden onset of chest pain. The patient is anxious and tachypnic. The initial priority intervention for the emergency nurse to perform for this patient would be to administer supplemental oxygen

Although an appropriate intervention, it is not a priority. Ensuring adequate oxygen exchange through administration of supplemental oxygen is the priority intervention for this patient. An echocardiogram is an ultrasound diagnostic tool to determine the function and structure of the heart. Although obtaining IV access is an appropriate intervention, it is not the priority. Category: Respiratory Emergencies/Pulmonary Embolus

Raynaud's disease is characterized by which assessment findings? Intense vasospasms and pallor of the digits

Although leg cramps and redness may be associated with peripheral vascular disease, Raynaud's disease typically effects the fingertips. Carpopedal spasms may be caused by low blood calcium levels and has been associated with electrolyte disturbances connected to the presence of tetanus infections. Raynaud's disease affects blood vessels supplying the skin. Intense vasospasms are noted to the digits, tip of the nose, or ears. Because circulation is impaired, pallor is also noted, especially in cold environments. The disease effects women more than men and may also affect motor function. Numbness and tingling are generally associated with the presence of a nerve injury. Category: Cardiovascular Emergencies/ Peripheral Vascular Disease

A patient presents to triage with a complaint of continuous chest pain for the past 3 days. VS are 108/70, HR 68, RR 18, 99% on RA, 98.6. The patient describes the pain as sharp, located on the right side of the chest, and made worse by breathing and arm movement. The patient denies SOB or any trauma or recent surgeries, but the patient does report having an URI the previous week. The ED nurse anticipates which of the following diagnoses? Costochondritis

Costochondritis is an inflammation of the costal cartilage and can present as sharp pain that is worse on breathing in or with movement. Because the pain is reproducible, it is most likely related to costochondritis, which can occur following URIs, particularly when patients have been persistently coughing. Category: Maxillofacial, ocular, ortho, and wound emergencies/ortho/costochondritis

An elderly patient arrives to the ED via EMS with profuse epistaxis that has persisted for over an hour. After initiating universal precautions, the next priority intervention for the emergency nurse to perform is which of the following? Maintain airway patency

Although vital signs are important to obtain, they should never take priority over assessing airway patency. This patient will need IV hydration because of the duration of the bleeding and suspected blood loss, but assessing and maintaining airway patency is always the first priority. Posterior nasal bleeding can interfere with a patient's airway patency. Posterior bleeding can be chronic and is most common in elderly patients who may have a history of hypertension and who take an anticoagulation-type medication. This maneuver is effective with anterior nasal bleeds but will not act to minimize the amount of bleeding in the posterior nasal bleed. Anterior nasal bleeds usually arise from the area of the Kiesselbach plexus. This patient is demonstrating signs and symptoms of a posterior bleed. Category: Maxillofacial, Ocular, Ortho, and Wound Emergencies/Maxillofacial/Epistaxis

A patient presents to the emergency department complaining of lower abdominal pain and the inability to void in the past 24 hours. What is the priority intervention the emergency nurse should perform? Insertion of urinary catheter

Although vital signs are important, relieving bladder pressure is the priority. Bladder calculi is one of several etiologies that may be responsible for urinary retention; however, the priority intervention is to relieve the bladder pressure and prevent bladder rupture. This is accomplished by the insertion of an indweliling urinary catheter. A lack of urinary output may be related to fluid volume status, however, the patient's absolute inability to void, along with lower abdominal discomfort, strongly suggests that urinary retention, not hypovolemia, is the underlying problem to be addressed. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical Emergencies/Genitourinary/Urinary Retention

Following the insertion of an intraosseous (IO) device, which of the following findings by the ER nurse would indicate that the IO has been properly place? A reddish, frothy aspirate is noted after insertion.

As the IO device is placed in the bone, no movement should occur. Movement of the IO device could indicate improper placement, or the insertion hole in the bone has been drilled too large for the device to be secure. Bone marrow is reddish and frothy, not bright red blood. Blood present in the cannula could indicate unintentional placement of the IO needle int oa blood vessel. Following an initial isotonic crystalloid solution bolus to clear the cannula and open any connective tissue, fluid or medications administered through the IO needle should flow freely without the use of positive pressure. The fluid will only flow as accomodated by the diameter of the marrow cavity. The marrow cavity does not expand with the use of pressure to infuse medications or fluids. As the IO device is inserted, marrow may be aspirated. During emergent situations, the aspirated marrow may be used for some lab testing. Category: Cardiovascular Emergencies/Trauma

When providing discharge instructions to the parents of a child, the nurse is aware the parents have understood the importance of avoiding products that contain aspirin when they state which of the following? There is an association between the use of aspirin-containing products in febrile children and the development of Reye's syndrome.

Aspirin-containing products should not be given to children with an acute febrile illness because of their association with the development of Reye's syndrome. Reye's syndrome is a rare yet rapidly progressing syndrome that results in encephalopathy. Other factors associated with the syndrome include use of aspirin during a viral illness, after which fatty deposits in the liver lead to altered mental status and altered glucose regulation. The immature pediatric neurologic system increases the risk for febrile seizures. Aspirin is an effective antipyretic but is contraindicated for use in the pediatric population. Aspirin has a similar onset of action compared to other antipyretics but is contraindicated. The immature neurologic system in the younger child increases the risk for febrile seizures. Aspirin is a known trigger for asthma in some patients but has not been shown to increase the incidence of asthma. Category (Pediatric): Psychosocial and Medical Emergencies/Medical/Fever

When caring for a child who has been treated for an asthma exacerbation, the ED nurse identifies that the patient is ready for discharge when: The patient's peak expiratory flow is greater than 70% and response is sustained for 60 minutes following the last bronchodilator treatment.

Assessment findings and improved peak expiratory flow are better indicators of success at home than return demonstration of medication administration. Results of interventions should be measurable and sustained. A peak expiratory flow or forced expiratory volume measurement is objective and reliable in assessing for airflow obstruction. Category (Pediatric): Respiratory emergencies/asthma

During triage, the patient states the pacemaker only fires when the patient's heart rate slows below a certain number of bpm. The nurse anticipates that the patient has a demand pacemaker

Asynchronous is another name for fixed-rate pacemaker. A fixed-rate pacemaker will continue to deliver an impulse to "fire" regardless of the patient's intrinsic heart rate. A demand pacemaker has the capability to sense the patient's intrinsic heart rhythm and only delivers an impulse to fire when the patient's intrinsic heart rate falls below a given rate. Dual-chamber pacemakers provide electrical stimulation to both atrial and ventricular chambers, based on the patient's intrinsic heart rate. Category: Cardiovascular emergencies/dysrhythmias

Which type of skull fracture would place the patient at the highest risk for developing an intracranial infection? Basilar skull fracture

Basilar skull fractures include the fracture of any of the five bones at the base of the skull. T hese fractures can cause a laceration of the dura mater, resulting in an open passage of cerebrospinal fluid, which places the patient at risk for intracranail infections such as meningitis, encephalitis, and or brain abscess. A linear skull fracture is a nondisplaced fracture of the cranium and does not increase the risk of intracranial infections. A depressed skull is a fracture extending below the surface of the skull and lacerating the dura mater, which may cause intracranial infections; however, the incidence of infection is statistically higher in basilar skull fractures. Temporal b one fractures increase the risk of epidural hematoma. Trauma Nursing Core Course: Provider manual 7th ed. pp. 105-122 Category: Neurological Emergencies/Trauma

A patient presents to the ED following a bar fight. The patient reports being punched in the face and having their neck forced backward. A few hours later, the patient began noticing upper extremity weakness with associated sensory loss. They also report being unable to urinate, and the bladder scan reveals 300 mL of urine in their bladder. The most likely cause of this patient's symptoms is: Central cord syndrome

Brown-Sequard syndrome is consistent with hemiparaplegia on the same side as the cord injury and hemianesthesia on the opposite side of the cord injury, but below the level of injury. Anterior cord syndrome is consistent with motor paralysis and a loss of pain and temperature sensation below the level of injury, with a preservation of proprioception, touch, and vibratory sense. Central cord syndrome results from a hypertension injury of the cervical spinal cord. Common symptoms include upper and lower extremity weakness, with deficits more pronounced in the upper extremities. In addition, the patient may experience varying degrees of sensory loss, impaired pain, temperature, light touch, and position sense below the level of the injury. These symptoms may also lead to a neurogenic bladder. Symptoms are usually self-limiting. Posterior cord syndrome is consistent with preserved motor function below the level of the injury, with a loss of sensory function. Category: Neurological emergencies/spinal cord injuries

A patient is being discharged from the ED for treatment of carbon monoxide poisoning. The ED knows that the patient understands their discharge instructions when the patient states: "I will not use a space heater."

Carbon monoxide poisoning from faulty heaters or inadequate ventilation in the winter is the most frequent source of poisoning in the US. The use of space heaters in small enclosed spaces can contribute to carbon monoxide poisoning. Accompany symptoms of carbon monoxide poisoning include loss of memory and concentration, personality changes, irritability, and extreme fatigue. Category: Environment and Toxicology Emergencies, and Communicable Diseases/Toxicology/Carbon monoxide

An adult patient with a history of asthma presents to triage stating they are experiencing an cute asthma exacerbation. The emergency care provider orders an ECG. The patient asks why this procedure is necessary. The nurse explains to the patient: In adults, underlying cardiac conditions can often present as, or exist with, respiratory complaints."

Cardiac conditions, such as ST elevation myocardial infarctions (STEMI) and dysrhythmias, can cause respiratory distress. Respiratory inefficacies can lead to myocardial irritation. All adult patients should have an ECG to rule out any coexisting cardiac conditions. Category: Respiratory Emergencies/Asthma

A patient presents via EMS in cardiopulmonary arrest, following 15 minutes of CPR. On completion of the initial nursing assessment, which of the following findings would indicate that termination of resuscitation efforts should be considered. An end-tidal CO2 level reading less than 10% after 20 minutes of high-quality CPR

Changes in bag-mask device compliance may indicate development of a pneumothorax, which requires immediate intervention to prevent development of a tension pneumothorax. A low end-tidal CO2 level indicates a lack of both end cellular perfusion and adenosine triphosphate production, resulting in cellular death. With an initial rhythm of pulseless electrical activity, there should be a review of potential underlying causes with initiation of the appropriate interventions before discontinuing. Early defibrillation of a shockable rhythm, such as ventricular tachycardia or ventricular fibrillation, is associated with a higher rate of survival. Category: Cardiovascular emergencies/Cardiopulmonary arrest

Which of the following human compensatory mechanisms to the presence of shock triggers glycogenolysis? Adrenal gland stimulation

Chemoreceptors are activated by changes in blood oxygen, carbon dioxide, and pH. Activation of the clotting cascade is associated with the trauma triad of death: hypothermia, acidosis, and coagulopathy. It is not directly related to glycogenolysis. Adrenal gland stimulation causes the adrenals to release two catecholamines: epinephrine and norepinephrine. Epinephrine increases heart rate and peripheral vasoconstriction and triggers glycogenolysis. Category: Cardiovascular Emergencies/Shock TNCC pp 73-90

Emergency medical services arrive with an unrestrained driver who was involved in a multivehicle collision. The patient is diagnosed with a pelvic fracture and left tibial racture. Which classification of hypovolemic shock would most likely occur as a result of these injuries? Class IV

Class IV hypovolemic shock occurs with blood loss greater than 2000 mL. Estimated blood loss from a pelvic fracture is 3000 mL and from a tibial fracture is approximately 650 mL. Severe signs and symptoms of hypovolemia would be present. Class III hypovolemic shock is defined as blood loss of 1500-2000 mL. With a possible blood loss of 3000 mL from the fractured pelvis and 650 mL from the tibia, the blood loss would be well beyond the Class III category. Class II hypovolemic shock is defined as blood loss of 750-1500 mL. Class I hypovolemic shock is defined as blood loss of less than 750 mL. An isolated tibia fracture might meet this criterion, but with the addition of a pelvic fracture, greater blood loss would be anticipated. Category: Cardiovascular Emergencies/Trauma

The key to safe and effective care of a trauma patient is associated with which of the following? Identified roles and responsibilities of team members.

Clear and defined roles of each of the team members are key components to the safe and effective delivery of trauma care. The trauma team needs to be able to communicate effectively with one another to minimize errors and to improve patient outcomes. The trauma team needs one identified leader from which all members of the team receive direction. This will lead to minimal errors, better team organization, and the development of clear goals. A well-organized trauma team will conduct a review of the entire trauma resuscitation and critique how they can improve their communication for optimal patient outcomes. Category: Professional Issues/Nurse/Evidence-based Practice

A patient with a history of diabetes presents to the ED complaining of increased swelling and severe pain in the left eye with movement of the eye. On assessment, the patient demonstrates decreased visual acuity, decreased pupillary reflexes, and the presence of erythema and edema of the upper and lower eyelids and of the left cheek area. The emergency nurse anticipates the patient has signs and symptoms of: Orbital cellulitis.

Conjunctivitis involves the eyelid and conjunctiva and results in redness, some edema, and drainage. Conjunctivits does not affect the patient's visual acuity. The patient will usually not experience pain with eye movement. Anterior uveitis is the inflammation of the upper eyelid. It is associated with the presence of excessive tearing, redness of the ye, and decreased visual acuity. Pain will not be present with eye movement. Iritis is the inflammation of the iris, resulting in pain, edema, tearing, and sensitivity to light, with some decrease in visual acuity. Pain is not present with eye movement. Orbital cellulitis is a serious emergency that involves the eye itself, resulting in painful movement, reduced visual acuity, and severe swelling and redness of the orbital area. Patients who are immunocompromised or who have a history of diabetes are mores susceptible to complicating infections. Orbital cellulitis is considered a life-threatening infection process because of the potential for the infection to enter the brain, resulting in meningitis. Category: Maxillofacial, Ocular, Orthopedic, and Wound Emergencies/Maxillofacial/Infections

Which of the following conditions caused by an insufficient amount of available antidiuretic hormone results in the patient urinating large amounts of diluted urine? Diabetes Insipidus (DI)

DI is a life-threatening condition caused by insufficient production of ADH by the hypothalamus, or insufficient ADH being released by the posterior pituitary gland. The patient will excrete large amounts of dilute urine and complain of fatigue and weight loss. Treatment for DI is fluid replacement and ADH replacement with meds such as desmopressin acetate (DDAVP). Adrenal crisis, also known as acute adrenal insufficiency, is a life-threatening condition caused by a decrease in cortisol and aldosterone levels. This results in sodium and water loss from both the kidneys and GI tract, causing the patient to become hypotensive and hypovolemic. As the body loses sodium, an increase in potassium occurs, leading to hyperkalemia and the development of fatal dysrhythmias. Syndrome of inappropriate antidiuretic hormone (SIADH) is a life-threatening condition in which the pituitary gland releases excessive amounts of ADH. The patient will present with dilutional hyponatremia and water intox, which can result in seizures. The patient will also complain of headache, fatigue, and weight gain without the presence of edema. Treatment for SIADH depends on the severity of the patient's hyponatremia. Fluid restriction should be initiated. Severe hyponatremia is treated with hypertonic saline and the administration of furosemide. Cushing's syndrome is the result of prolonged exposure to glucocorticoids, either endogenous or exogenous causing the patient to develop a cushingoid appearance. There is an increased amount of adipose tissue to the face, upper back, and base of the neck. Category: Psychosocial and medical emergencies/medical/endocrine conditions

The ED nurse would anticipate arterial blood gas values from a patient in severe COPD exacerbation to illustrate: Respiratory acidosis

Damaged alveoli do not efficiently exchange oxygen and carbon dioxide. Retained CO2 lowers the overall pH of the blood, resulting in respiratory acidosis. Category: Respiratory Emergencies/COPD

In caring for a patient with multiple sclerosis, the ER nurse is aware that a common healthcare issue that affects the quality of life in this patient population is Depression

Depression is common among patients with MS And often goes undiagnosed. Category: Neurological emergencies/chronic neurological disorder

Which of the following laboratory test values would alert an emergency nurse that a patient with disseminated intravascular coagulation is beginning to improve. Increased platelet count

Disseminated intravascular coagulation (DIC) can cause an elevation in both d-dimer and fibrin degradation factor. A continual d-dimer increase would indicate progression of the disease, not an improvement in the patient's DIC. DIC causes a massive consumption of platelets, which leads to the extensive clotting that occurs, therefor, an increase in the patient's platelet count would indicate that the DIC is lessening and the patient is beginning to improve. The pathophysiology of DIC is one of a prolonged partial thromboplastin time (PTT); therefore, a continued prolonged PTT would not indicate improvement in the patient's condition, but rather that the DIC is continuing. An increase or prolongation of the prothrombin would be a pathophysiological response, not a physiological response, and therefore would not indicate patient improvement. Category: Psychosocial and Medical Emergencies/Medical/Disseminated Intravascular Coagulation (DIC)

A 32-year-old female who is 28 weeks pregnant presents with RUQ pain that is radiating to the right scapula area. The patient states that the pain began a short time after having dinner. Based on the patient's presentation, the most likely diagnosis is: Cholecystitis

Diverticulitis is caused when the diverticula become inflamed. Pain is persistent and localized to the left lower quadrant. It is commonly described as left-sided appendicitis." Symptoms of cholecystitis include a sudden onset of abd pain that is usually associated with ingestion of fatty or fried foods. Pain is located in the epigastrum and/or upper right quadrant. Pain may be referred to the right shoulder or supraclavicular area. Pain with pancreatitis is generally located in LUQ or epigastrum and may radiate through to the back. Gastroenteritis is common GI illness that may have a viral or bacterial origin and may occur following the ingestion of contaminated foods. Symptoms include n/v/d, and abd cramps. Category: GI, GU, Gyn, and OB Emergencies/GI/Cholecystitis

Accurate documentation of the "chain of custody" in the handling of forensic evidence is necessary to ensure which of the following? Safeguarding the integrity of the evidence.

Documentation of a chain of custody does not validate the competence of the evidence collector; it only provides a detailed account of when the evidence was collected, secured, and properly transferred without interference, potential contamination, or loss. Accurate documentation of the chain of custody when handling forensic evidence establishes the integrity o the evidence and ensures that it was not subject to contamination or tampering. The best practice in forensic evidence collection is to limit the number of individuals who handle the evidence. Category: professional issues/patient/forensic evidence collection

When suspecting the presence of child maltreatment or neglect in a patient, the emergency nurse is required to: Report the suspected abuse or neglect to the police and child protective services.

Documentation of facts is important in the potential child maltreatment or neglect case. The name of the abuser may or may not be known, however, the proper local authorities must be notified of the suspected abuse or neglect. In some cases, this may not be beneficial to the welfare of the child. The parent may attempt to leave the ED if notified of the report to police or child protective services. Nurses are mandatory reporters for suspected child maltreatment or neglect. Failure to report may result in possible civil or criminal charges being brought against the nurse. A child's prior pediatrician records or visits may be researched in a case of child maltreatment or neglect, but only after obtaining permission from the provider. Category (Pediatric): Psychosocial and Medical Emergencies/Psychosocial/Abuse and neglect

Which of the following patients should receive rabies prophylaxis? The patient who may or may not have been bitten by a bat in the house

Domestic cats are usually vaccinated against rabies. Bites from any animal that can be observed for 2 weeks usually do not require rabies prophylaxis. Domestic dogs are usually vaccinated against rabies. Bats are common carriers of rabies, and prophylaxis is recommended when someone has been either exposed or bitten by a bat. Category: Environment and Toxicology Emergencies, and Communicable Diseases/Environment/Vector-borne illnesses: rabies

A patient who is 6 days postpartum and breastfeeding presents to the ED complaining of fever, with right-sided breast redness and tenderness. The patient is diagnosed with mastitis. In addition to antibiotic therapy, which of the following should be included in the discharge instructions for this patient? Apply a warm compress to the breast before breastfeeding.

Emptying the breast is an important component in the management of mastitis. The use of a hand or mechanical pump is recommended, particularly if the infant is unable to effectively nurse. Breastfeeding should be continued because treatment involves emptying the breast. Mastitis does not change the taste or nutritional value of breast milk. Breastfeeding should be continued because treatment includes emptying the breast. Warm compresses or a hot shower will help alleviate symptoms associated with mastitis and facilitate milk flow.

A patient is brought to the ED after exhibiting aggressive behavior toward family members. To assess the patient's current mental state, which question would be most important for the ED nurse to ask the patient? What are the voices telling you to do?

Establishing details of the patient's hallucinations yields information into their suicidal or homicidal ideations. It is important to know what auditory hallucinations may be occurring for the patient who is aggressive or violent so that the proper security measures can be initiated. Category: Psychosocial and Medical Emergencies/Psychosocial/Aggressive/Violent behavior

The ED nurse is caring for a victim of sexual assault. Which of the following statements made by the victim indicates the need for further education regarding the sexual assault examination process? I will need to be seen again in about 1 week to have more cultures taken.

Following the examination and collection of evidence, the patient is allowed to shower, and clean clothing should be made available. Being anxious is an expected response to the entire sexual assault experience. The patient may need emotional support, but more education about the actual process will probably not act to lessen the anxiety the patient is experiencing at this time. Unless the patient requests an officer to be present during the examination, it is not done. Sexually transmitted organisms such as chlamydia and gonorrhea that are transmitted during a sexual assault may not be present in sufficient quantity to yield a positive culture result at the time of initial examination. The patient should be instructed to obtain follow-up care within 1 week to obtain additional culture specimens. If the patient received prophylactic treatment, cultures should be obtained if the patient reports having symptoms. Category: GI, GU, Gyn, and OB Emergencies/Gyn/Sexual Assault/Battery

A patient with a history of esophageal varices presents to the ED complaining of weakness and diaphoresis. The patient suddenly has an emesis of bright red blood. The priority intervention for the ED nurse to perform is: To establish intravenous IV access with two large-caliber IV catheters.

Gastric tube insertion should be done carefully to avoid inadvertent esophageal rupture. Insertion may be indicated, but treatment of hypovolemia is the priority. The evaluation of hemodynamic status through VS measurement is important in ongoing evaluation but is not a priority in light of the patient's active bleeding. Administering oxygen to this patient is an important intervention however, the use of a nonrebreather mask would not be effective for a patient who is actively vomiting blood. Therapeautic interventions should focus on the management of bleeding and hypovolemic shock. Category: GI, GU, Gyn, and OB Emergencies/GI/Esophageal varices

A patient arrives to the ED with a 2-week history of repeatedly falling, accompanied by ascending weakness and tingling in the feet and fingeres. There is loss of the knee-jerk reflex, and the patient is complaining of being unable to take a deep breath and of overall difficulty in breathing. VS are 120/70, HR 72, RR 22, 96% on RA. The ED nurse suspects the patient may have which of the following? Guillain-Barre Syndrom

Guillain-Barre syndrome, also called acute inflammatory demyelinating polyneuropathy (AIDP), is characterized by the rapid onset of numbness, weakness, and often paralysis of the legs, arms, breathing muscles, and face. Paralysis is ascending, meaning that it travels upward from the toes, upward along the lower extremities, and from the fingers along the upper extremities toward the torso. Absence or loss of tendon reflexes is also evident as GBS progresses. Category: Neurological Emergencies/Guillain-Barre Syndrome (GBS)

A patient who is diagnosed with a chlamydia trachomatis vaginal infection should also be screened for what other associated sexually transmitted disease? Gonorrhea

HPV is the most common std in the US. HPV is frequently associated with cervical dysplasia but not with other stds. Bacterial vaginosis is not a std; rather, it is caused by a disturbance in the normal vaginal flora. Most cases of candida infection are caused by the person's own candida organisms. Candida yeasts usually live in the mouth, GI tract, and vagina without causing symptoms. However, when an imbalance occurs, such as when the normal acidity of the vagina changes or when hormonal balance changes, Candida can multiply and build up. When this occurs, the patient can experience signs and symptoms of candidiasis. Chlamydia is an STI caused by chlamydia trachomatis bacterium. Chlamydia and gonorrhea often occur together. Category: GI, Genitourinary, Gynecology, and Obstetrical Emergencies/gynecology/infection

Which statement is correct regarding hemophilia disorders? Hemophilia is an inherited sex-linked genetic disorder.

Hemophilia is a sex-linked genetic disorder and is very rare in females. Treatment for hemophilia may include replacement of factor and administration of plasma or cryoprecipitate. Platelets are administered as part of the treatment for severe thrombocytopenia. The mother is the carrier and passes the train on to her children. Active disease is most often expressed in males. Complications from hemophilia are often seen with trauma and invasive procedures. Category: Psychosocial and Medical Emergencies/Medical/Blood dyscrasias: Hemophelia

Parents of a 7-month-old state the infant has not been as active as usual and has been crying and drawing up their legs at intervals. The child's abdomen is distended, and a mass is palpable in the right upper quadrant. The parents state that earlier today, the child had a small BM that looked red with mucous in it. The child's symptoms are most consistent with which of the following conditions? Intussusception

Intussusception is the telescoping or prolapse of a segment of bowel into an adjacent segment, "causing the classic symptoms of abd pain, a palpable abdominal mass, and "currant-jelly stools" with bloody mucus. It is more commonly seen in children between the ages of 3 months and 5 years. Sudden, acute, cramping pain and the child drawing up their legs are the most commonly reported signs. The child may be pain free between episodes. Pyloric stenosis causes muscular thickening of the pylorus, leading to a functional gastric outlet syndrome. This disorder is the most common cause of intestinal obstruction in infancy. The infant typically presents with a previously normal feeding history and suddenly develops projectile emesis after eating. Occasionally an olive-shaped mass can be palpated in the RUQ. Acute appendicitis is the most common causes of abd pain. Classic symptoms include constant abd pain, fever, and vomiting. The pain may start as periumbilical and migrate to the RLQ. Appendicitis occurs in all age groups but is rare in infants. An incarcerated hernia typically presents as an asymptomatic bulge of a bowel loop that becomes more prominent with crying, laughing, or coughing. If circulation to the bowel loop is compromised, symptoms wound include pain and swelling at the site of herniation, nausea, and vomiting, and signs of a bowel obstruction. In children, these hernias are most commonly found in the inguinal area where firm tender masses can be palpated in the inguinal canal or scrotal area. Category (Pediatric) GI, GU, Gyn, OB Emergencies/GI/Intussusception

Which of the following interventions would be appropriate for an emergency nurse to perform following the transfer of a patient? The patient has experienced an cute psychotic episode and states, "I'm coming back here when I get released from the hospital, and I am going to kill Jane Smith." Alert proper law enforcement authorities.

It would be egregious to ignore something of this nature and not report the threat to both the proper authorities and the individual being named. It is important that proper authorities be notified when patients make statements that are very specific in nature and when they name a particular person. That person should be aware of the threat and should be provided the proper protection. Informing the patient that this is inappropriate will provide no protective care to the individual named and would not be of any benefit to the patient in their current mental state of being. The hospital chaplain would not be an appropriate person to intervene and speak to the patient regarding the threat they have made. This could be an idle threat, or it could be real. It is not appropriate for nonmedical individuals to determine whether the patient's threat is real. Category: Psychosocial and Medical Emergencies/Homicidal Ideation

Correct placement of an NG tube is best confirmed by which method? Obtaining a chest radiograph

Measuring the pH value of stomach aspirate has limited value in the clinical setting because many patients are on acid-inhibiting medications. These medications will alter the pH level of the stomach contents. Radiographic confirmation of proper NG tube position is the most reliable method to ensure correct placement. Placing the end of the NG tube in a container of water and observing for bubbling is an inaccurate and potentially dangerous practice to confirm NG tube placement. If the NG tube is in the airway, the patient may aspirate on inhalation. Instilling air into the NG tube while listening with a stethoscope over the epigastrum for the associated "whoosh" sound has been found to be an unreliable method of verifying NG tube placement. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical Emergencies/Gastrointestinal/Obstructions

A patient presents to the emergency department via EMS. The patient has cervical spine precautions in place because of suspected spinal cord injury. Per the EMS report, the patient initially was able to move their wrists bilaterally. On initial assessment, the emergency nurse determines that the patient is only able to shrug their shoulders. The priority intervention for this patient would be to: Notify the trauma team

Movement of the wrists is a function of C7 innervation. Movement at only the shoulders would reveal a worsening condition because this motion would be the result of innervation at the level of C6 and the loss of C7 function. The patient will require immediate diagnostic studies and treatment as deemed necessary by the trauma team. Category: Neurological Emergencies/Spinal Cord Injuries

A heart failure patient with profound dyspnea, lung crackles, and pink frothy sputum presents to the ED. The physician orders for the patient to be placed on biPap at an end-expiratory pressure of 10 and an inspiratory pressure of 5. Which of the following findings demonstrates that the patient's symptoms and work of breathing have been reduced? Decreasing the preload

Noninvasive positive airway pressure ventilation (NIPPV) decreases preload and blood flow into the right side of the heart. NIPPV improves cardiac output by the reduction in preload and afterload. NIPPV includes both CPAP and BiPAP devices. By increasing the pressure within the thoracic cavity through NIPPV, blood flow into the right heart is reduced; this results in a decreased preload, which helps to improve pulmonary congestion in the acute HF patient. BiPAP decreases afterload indirectly; it enables forward flow of blood to occur more easily because of the increased intrathoracic pressure on the left ventricle. Category: Cardiovascular Emergencies/Heart failure

An adolescent patient was brought in by ambulance from a party at a friend's house. Paramedics report that the patient was drinking an unknown amount of alcohol at the party. The patient is lethargic and only responds to painful stimuli by moaning. VS are 110/60, HR 122, RR 14, 94% RA, 97.1. Which of the following diagnostic studies has the highest priority for this patient? Serum glucose level

Obtaining a serum glucose level is a priority to determine if hypoglycemia is present. Hypoglycemia is a common occurrence in alcohol toxicity, and it could also be the cause of the patient's altered level of consciousness. Severe hypoglycemia can be fatal. Category (pediatric): Environment and toxicology emergencies, and Communicable diseases/toxicology/substance abuse

A patient presents with a 24-hour history of abdominal pain, fever, nausea, and watery diarrhea. On further questioning, the patient states that they have been prescribed bactrim for a UTI. What would your primary intervention be for this patietn? Place the patient in a private room on contact isolation.

Obtaining a stool sample to send for culture is common. However, these results take 48-96 hours, so the higher priority would be to isolate the patient. Patients with known or suspected C. Diff infections should be immediately placed on contact isolation to prevent spread to other patients and staff. C. Diff is a highly contagious bacterium causing colitis in the large intestine. The bacteria may colonize or grow when a patient is on antibiotics and normal intestinal flora are disrupted. Patients are capable of shedding the bacteria for several days after symptom resolution. Stool is highly contagious, and contact precautions should be implemented. A normal saline bolus may be indicated based on the patient's hydration status. Antibiotics are the standard treatment; however, getting the patient to a private room and isolation would be higher priority. Category: Environment and Toxicology Emergencies, and Communicable Diseases/C. Diff

A patient is being discharged following treatment for excessive vomiting and diarrhea from a possible foodborne illness. You know the patient understands the discharge instructions when the patient states: I will drink clear liquids, such as sports drinks, for the next 24 hours.

Once vomiting has been controlled, oral hydration should begin with the use of fluids that contain glucose, sodium, and potassium, such as sport or electrolyte replacement drinks. Institution of a regular diet following vomiting and diarrhea may induce the vomiting and diarrhea again. Patients should be instructed to gradually increase their diet as tolerated. Milk or milk productes are not recommended following vomiting and diarrhea. Clear liquids are defined as liquids that a person can see through, such as water, fruit juice without pulp, broth, clear sodas, jell-o, and popsicles. Milk and orange juice are not defined as clear liquids. Emergency nursing core curriculum 6th edition pp. 159-186 Category: Environment and Toxicology Emergencies, and Communicable Diseases/Environment/Food Poisoning

An adult patient presents to the ED with a thermal burn to the right forearm. The burn is very painful and sensitive to air. The patient's forearm area is red, involving the first few layers of the dermis, with a large fluid-filled blister. The nurse would appropriately classify the burn as a: Deep partial-thickness burn

Only the epidermis is involved with superficial burns. The skin is red and painful. Superficial burns do not have blistering. Fourth-degree burns involve underlying tissues, including muscles and tendons. Deep partial-thickness burns are very painful and involve only the first few layers of the dermis. Blistering is common with deep partial-thickness burns. Full thickness burns involve subcutaneous tissue and do not include blistering. These burns may be surrounded by deep partial or superficial partial burns. Category: Environment and Toxicology Emergencies, and Communicable Diseases/Environment/Burns

A 3-year-old child who weights 20 kg is being treated for a 2-day hx of vomiting and diarrhea. The child has been orally rehydrated and is now being discharged home with parents. Which of the following would be most important to include in the initial home care discharge instructions? Administer 1-2 tsp of an oral rehydration solution (pedialyte) every 5 minutes

Oral rehydration therapy can be continued at home. The parents should be instructed to administer the solution in sips of 1-2 teaspoons per hour to promote absorption and prevent vomiting. After 2 days of vomiting and diarrhea, the priority for this patient is oral rehydration. The reintroduction of solid food too quickly is likely to induce additional vomiting. Category (Pediatric): GI, GU, Gyn, and OB Emergencies/GI/Gastroenteritis

Which of the following statements made by a patient recently diagnosed with peripheral vascular disease indicates that the patient has an accurate understanding of the disease? When my legs start to cramp, I should stop walking and rest.

Pain from PVD can develop while exercising, experiencing stress, and being in a cold environment. It can be relieved by removing or discontinuing the cause. Pain is exacerbating by a cold environment, a warm environment will help relieve the pain. Application of direct heat source to the ischemic area could result in further harm to tissue. The affected limb should not be elevated above the level of the heart because this will result in increased pain and cramping because peripheral blood flow to that area has been decreased. Cigarette smoking has been identified as a major risk factor for the development of PVD. Other risk factors include hypertension, hyperlipidemia, diabetes, obesity, and a sedentary lifestyle. Category: Cardiovascular Emergencies/Peripheral Vascular Disease

Which assessment finding in a patient with adrenal crisis would alert the emergency nurse to prepare for an expected complication? Hypotension

Patients in adrenal crisis are at risk for hyperkalemia, not hypokalemia, because of the presence of insufficient adrenal hormones. Patients in adrenal crisis have significantly low levels of cortisol and aldosterone. The risk of developing hypoglycemia, hyponatremia, hypovolemia/hypotension, and hyperkalemia is significant. The presence of hypotension should alert the nurse to the need for fluid resuscitation and immediate replacement of adrenal hormones. Because of severe hypotension, patients in adrenal crisis are often tachycardic and do not experience bradycardia. Category: Psychosocial and medical emergencies/medical/endocrine conditions: Adrenal

The nurse is providing discharge education for an adult patient diagnosed with an infestation of scabies. Which of the following patient statements indicates the patient understands the discharge instructions? It is normal to continue to experience itching for up to 7 days following treatment.

Patients may return to work or school after the first treatment for scabies. Discarding clothing and linens is an option, but washing the it ems in hot water and then placing them in a hot clothes dry also is acceptable. It is common for patients to continue to have an itching sensation for up to 1 week following treatment. Patients should not be retreated without consulting provider. Scabies is highly contagious, and members of the household may also require treatment. Category: Environment and Toxicology Emergencies, and Communicable Diseases/Environment/Parasite and fungal infestations

Using the mass casualty START Triage system for adults, which of the following patients would be classified as a yellow (delayed) patient? A patient who is unable to ambulate and who can follow commands, with a RR under 30 bpm

Patients who are able to ambulate unassisted and walk to the designated area are classified as "walking wounded," or the green simple triage and rapid treatment (START) triage category. This patient is classified as red in the START triage category because of a respiratory rate over 30 BPM and being unable to ambulate. Patients who do not have spontaneous respirations after repositioning of their airway are classified as black (expectant). Additional classifyign criteria do not matter because this patient is not breathing and is considered expectant; attempting resuscitative measures in a mass casualty incident would require more resources than are potentially available. Patients who are unable to ambulate but meet the START triage criteria of a respiratory rate less than 30, cap refill of less than 2, and are able to follow commands fall into the yellow START triage category. Category: Professional Issues/System/Disaster Management

A patient with a history of leukemia and who is currently undergoing chemotherapy treatment is being discharged from the ED following a facial lac repair. Which statement best indicates to the ED nurse in the patient's understanding of the discharge instructions? I might not see the common signs of infection.

Patients who are immune-compromised are generally neutropenic and are at great risk for infection. Becaus the body's phagocytic response is impaired, the typical signs of infection, such as redness, swelling, or pus, may not be seen in this patient populations. Patients on chemotherapy have low WBC counts. Patients on chemotherapy and generally neutropenic and may not experience phagocytosis even if they have an infection. Category: Psychosocial and Medical Emergencies/Medical/Blood dyscrasias: Leukemia

A patient presents to the ED with abd pain and "ripping" back pain. Which condition places the patient at risk for abdominal aortic dissection? Ehler-Danlos syndrom

Patients with Ehler-Danlos syndrome may be identified by hypermobile joints and skin that is hyper-extensible, has a soft, velvety-like appearance, is fragile, and tears or bruises easily. Ehler-Danlos syndrome is a connective tissue disorder that places patients at risk for the presence of aortic aneurysm and dissection. Category: Cardiovascular emergencies/aneurysm/dissection

The emergency nurse is caring for a patient with the following symptoms: severe headache, neck stiffness, fever, and inability to tolerate bright light. The patient has been administered intravenous antibiotics and an antipyretic for fever. The nurse identifies additional patient education is required for their diagnosis of bacterial meningitis when the patient states: I will take antibiotics until my symptoms go away

Patients with meningeal disease are contagious, and chemoprophylaxis is required for anyone who is exposed directly to oral secretions of the infected individual. Patients with meningeal disease are contagious and should limit their interactions with others until their symptoms are no longer evident. Patients should take their fever-reducing medications until their fever is under control to minimize their discomfort and prevent further complications. The patient's symptoms are indicative of viral meningitis. Patients with meningitis are contagious, requiring antibiotics and observation for potential complications. Category: Neurological Emergencies/Meningitis

A patient presents with fever and a small, flat, pink nonpruritic macular rash on the palms of their hands and soles of their feet. The patient describes removing a tick from their forearm several days ago. Which tickborne disease would you suspect this patient has? Rocky Mountain spotted fever

Patients with tularemia typically present with a skin lesion at the site of the bite, which may ulcerate in 2-3 days. Mild edema may be observed with regional adenopathy. Patients with Rocky Mountain spotted fever typically have a fever along with a flat, pink, macular nonpruritic rash. Occurring within the first 10 days following the bite, the rash generally on the palms, forearms, soles, and ankles. The rash will initially blanche and then becomes raised bumps. Nausea with vomiting can also occur as a result of the disease process. Lyme disease may present with a target or bull's eye rash with bright borders and a fading center. Patients present with malaise, viral syndrome, lymphadenopathy, and headache. Patients with Colorado tick fever present with flulike illness, including fever, chills, malaise, myalgia, and lethargy. No rash is typically identified. Category: Environment and Toxicology Emergencies, and Communicable Diseases/Environment/Vector-borne illnesses: Tick-borne illness

A patient c/o chest pain, dyspnea, and diaphoresis. Which of the following assessment factors would indicate a possible diagnosis of acute coronary syndrome? Chest pain that radiates to the shoulders, with pain in the right shoulder worse than pain in the left shoulder.

Pleuritic chest pain has a likelihood ratio of 0.2 -- low likelihood of predicting ACS. Positional chest pain has a likelihood ratio of 0.3, which is low. Chest pain that radiates to both shoulders has a ratio of 7.1. Pain that radiates to the right shoulder has a ratio of 2.9. Reproducible pain with palpation has a low likelihood ratio of 0.3. Category: Cardiovascular emergencies/Acute coronary syndrome

Which of the following is considered an appropriate treatment for a patient with a venomous snake bite? Immobilize the involved area at or below the level of the heart

Providing immobilization and maintaining the extremity at the level of the heart is considered appropriate therapy following a venomous snake bite. Ice application, tourniquets, and wound suction have been shown to worsen patient outcomes. Ice application has been proven to worsen patient outcomes following venomous snake bites because of tissue vasoconstriction. The extremity should be maintained at or below the level of the heart to minimize the risk of the snake venom entering the central circulation. The antivenin should be administered as directed within 4 hours of the bite. Antivenin has been shown to be effective for up to 24 hours following envenomation. Category: Environment and Toxicology Emergencies, and Communicable Diseases/Environment/Envenomation emergencies

A patient presents to triage with a complaint of a headache and appears anxious and restless. The patient tells the ED nurse that the "man at the desk" has followed the patient from Russia, where the patient worked for the CIA, and the headache began after the tracking chip implanted in their brain was activated. The nurse observes no one at the desk, and the patient has identification that indicates a local address and that they are a student at a nearby college. There is no indication of recent travel or corroboration of the information. The ED nurse suspects the cause of the patient's symptoms is related to: psychosis

Psychosis is a severe mental disorder in which a person lsoes the ability to recognize rality or relate to others. Symptoms include being paranoid, having false ideas about what is taking place or who one is, and seeing, hearing, or feeling things that are not there. Other associated mental disorders are schizophrenia and bipolar disorder. Category: Psychosocial and Medical Emergencies/Psychsocial/Psychosis

Parents arrive to triage with their child, stating that the child has demonstrated recent behavior changes that include extreme anger with family members, no desire to complete required tasks (attend school or do chores), racing thoughts with rapid speech, and impulsive actions. The ED nurse will be most concerned about which type of psychiatric disorder being demonstrated by the patient? Bipolar Disorder

Psychosis is an altered mental state in which the child experiences a variety of disturbances that affect their perceptions of reality. The presentation includes hallucinations, delusions, and disorganized speech patterns. New-onset psychosis in children is uncommon but may be seen with other psychiatric disorders such as severe anxiety, PTSD, or depression, or it can be related to an organic cause. ADHD is characterized by symptoms of inattention, hyperactivity, and impulsiveness. The child may frequently interrupt or intrude on others, have trouble completing tasks, or become easily distracted. It is estimated that two children in every classroom have been diagnosed with ADHD. Bipolar disorder is seen in many children who display inability to function in daily life because of frequent mood swings, often going from a depressive state to a manic state (speaking quickly or racing thoughts). Children will lose the ability to complete daily tasks such as going to school and completing chores, and they may experience mood swings with varying severity depending on the age of the child. Panic disorder is a severe form of anxiety. The presentation includes crying, possibly clinging to a parent or loved one, symptoms of chest pain or discomfort, choking sensation, sweating, dizziness, lightheadedness, fear of dying and a racing pulse. Category (Pediatric): Psychosocial and Medical Emergencies/Psychosocial/Bipolar disorder

A patient arrives via EMS following a house fire. The patient has a GCS score of 15. The ER nurse understands that the patient's airway is patent because: The patient is able to state their name clearly.

Pulse oximetry only detects saturated hemoglobin and does not differentiate b/t oxygen and carbon monoxide hemoglobin saturation, so the pulse oximetry reading will usually appear to be WNL. A carboxyhemoglobin level will be necessary to determine the presence of carbon monoxide in the patient's blood. Clear, audible speech indicates that there is no immediate threat to the patient's airway. The presence of clear and audible speech is the easiest way to determine a patent airway when rapid assessments are needed. Signs of inhalation injury include hoarse voice, stridor, wheezing, cough, and presence of carbonaceous sputum. An absence of the patient's ability to cough is usually indicative of airway obstruction. Category: Respiratory Emergencies/Inhalation Injuries

According to the Joint Commission, the overwhelming majority of serious medical errors that occur during patient handoff can be attributed to which type of mechanism? Communication Breakdown

The Joint Commission requires accredited organizations to use a standardized approach to handoff communications, citing research suggesting that approximately 80% of serious medical errors occur because of miscommunication rates during patient handoffs/transfers. The use of unapproved abbreviations contributes to medication errors. However, their use is only part of the communication process that takes part at the time of patient handoff/transfer. Category: Professional Issues/System/Risk Management

A patient presents to the ED complaining of two tonic-clonic seizure episodes within the previous 3 days despite being compliant with daily doses of Keppra. Which of the following statements made by the patient indicates that additional education is required with this medication? I limit alcohol to two drinks each night.

Regular exercise contributes to overall health status and may assist with stress and coping with chronic illness. Activities chosen should consider the potential for injury should a seizure occur. Regular sleep promotes general health, reduces stress on the system, and aids with coping. Keppra is excreted by the kidneys. Dehydration may cause concentration of medication, resulting in enhanced medication affects. Drinking alcohol may trigger seizures, even in small amounts. The CNS depressant effects of Keppra in combination with alcohol may enhance these effects, resulting in physical or mental impairment. Category: Neurological Emergencies/Seizure Disorders

An elderly patient presents to the ED complaining of blindness in the left eye. The patient reports a hx of two prior episodes that resolved after a few seconds and denies pain or recent trauma. The nurse anticipates the patient has experienced which of the following? Central retinal artery occlusion

Retinal detachment may be distinguished by the patient's visual complaint, such as the presence of floaters, a veil, or curtain, or flashes of light that affect their field of vision. A tear in the retina affects the eye's ability to perceive light. Acute angle-closure glaucoma is described a severe, sudden, painful onset; vision is described as blurre,d or seeing halos around lights, with photophobia. Visual acuity is decreased, and if left untreated, ti can result in permanent blindness. Anterior uveitis is a painful inflammation affected the uveal or the middle layer of the eye. The affectecd eye is reddened with excessive tearing, and the patient will complain of photophobia. The eyelid will also appear edematous. Central retinal artery occlusion is the sudden, painless, unilateral loss of vision caused by an embolis or thrombus. It may be preceded by sudden temporary vision losses lasting seconds to minutes, which is referred to as amaurosis fugax. Category: Maxillofacial, Ocular, Orthopedic, and Wound Emergencies/Ocular/Retinal artery occlusion

A patient is observed walking into the ED with a severely thoracic curve, or "humpback." The emergency nurse knows that this condition is referred to as: kyphosis

Scoliosis is a lateral deformity, or curvature of the spine. Lordosis is an increase in the lumbar curve, or swayback. Genu varum is a bow-legged appearance of the legs in children. Kyphosis refers to an increased thoracic curvature of the spine, or humpback. Kyphosis (dowager's hump) is a collapse of the spine that produces the appearance of a shortened trunk. Category (Geriatric): Maxillofacial, Ocular, Orthopedic, and Wound Emergencies/Orthopedic/Low back pain

A patient presents to triage with a c/o difficulty breathing, presence of a nonproductive cough, and "stabbing" chest pain. The patient reports a hx of CHF. On assessment, the emergency nurse auscultates diminished breath sounds, bilaterally. What additional information would be the most pertinent to obtain from the patient? Medications prescribed and compliance

Sick contacts are assessed when patients report respiratory symptoms because many respiratory illnesses are viral or bacterial in nature. However, noting decreased breath sounds and the patient's medical history, it is more relevant to collect additional information regarding the patient's history of congestive heart failure. Dyspnea, cough, and chest pain are symptoms caused by numerous respiratory conditions. However, lung sounds that are decreased may indicate fluid or air around the lungs. CHF causes increased hydrostatic pressure in the pulmonary vasculature, which leads to excess fluid collecting in the pleural space, known as pleural effusion. In this scenario, it is most pertinent to assess a patient's compliance related to managing their congestive heart failure because unmanaged heart failure is the leading cause of pleural effusions. Category: Respiratory emergencies/pleural effusion

A patient presents to the ED with possible signs and symptoms of compartment syndrome 2 days following surgery for a fractured left tibia/fibula. Which of the following would alert the patient may be experiencing possible organ failure? Dark, scanty urine

Significant muscle damage and cellular destruction releases myoglobin, a muscle protein, into the bloodstream. As the myoglobin enters the kidneys, it causes the appearance of dark red or brown urine. The myoglobin can also clog the renal glomerulus, resulting in an acute renal injury. If the myoglobin is not flushes from the kidneys with large amounts of fluid, permanent renal impairment or injury can result. Category: Maxillofacial, ocular, ortho, and wound emergencies/ortho/compartment syndrome

A patient is being discharged after being treated for the presence of a cough for 3 months and increasing shortness of breath with excretion. The patient has been diagnosed with COPD. The emergency nurse knows that the only proven medical therapy shown to reduce the progression and mortality of COPD is: Smoking cessation.

Studies have shown that the reduction of risk factors slows the progression of COPD. Eliminating cigarette smoking is the single most valuable therapy in the reduction of COPD. Bronchodilators are used to control symptoms but have no effect on airway iflammation, which is the main cause of worsening disease. Airway inflammation is a characteristic of COPD. Anti-inflammatory medications may decrease the frequency of exacerbations but have not been shown to improve lung function or decrease mortality. Pulmonary rehab can improve a patient's quality of life by increasing exercise tolerance, but it does not improve lung function. Category: Respiratory Emergencies/COPD

Which of the following may be a subtle sign of sepsis that should be considered by the triage nurse during the initial assessment of a patient presenting to the emergency department? Respiratory rate greater than 22 bpm

Systolic blood pressure less than 90 mm Hg is considered a subtle sign of sepsis. A cough, dyspnea, tachypnea, and a respiratory rate of 22 bpm have been found to be subtle signs of sepsis that should be considered during the assessment of a patient in triage. Cap refill greater than 2 may be subtle sign of sepsis. Category: Psychosocial and Medical Emergencies/Medical/Sepsis and septic shock

A patient presents to emergency triage and tells the emergency nurse that they are experiencing a severe thorbbing-type headache pain located over the frontall region. The patient has hx of polymyalgia rheumatica. The ED nurse suspects the patient's current discomfort is related to the presence of which of the following? Temporal arteritis

Temporal arteritis is also referred to as systematic arterial vasculitis and produces a severe frontal throbbing type of pain. Palpation over the temporal region results in severe discomfort for the patient. Patients who experience temporal arteritis have a history of polymyalgia rheumatica and are usually over the age of 50. Category: Maxillofacial, ocular, orthopedic, and wound Emergencies/Maxillofacial

A conscious pulseless patient with a continuous-flow left ventricular assist device and a history of end stage heart failure presents to the ED because of a low-flow alarm. The nurse anticipates performing which intervention first? Obtain a BP using a Doppler and sphygmomanometer

The "low-flow" alarm may be because of decrease preload from hypotension, dehydration, obstruction of the inflow or outflow (which would cause an increase in afterload) cannula, or disconnection of percutaneous leads. A mean arterial blood pressure (MAP) should be obtained by placing a Doppler over the brachial or radial artery and then inflating the cuff until flow is no longer heard. Once the arterial flow is heard again, this is the MAP. LVAD patients should have MAPs between 70 and 80 mm Hg. In a conscious patient, determining the patient's blood pressure will guide therapy and troubleshooting. The patient's LVAD corrdinator should also be contacted as soon as possible. Auscultation of the pump is prudent to determine if the pump is functioning properly. Device failure has been reported as the second most common cause of death in LVAD patients. Signs of pump failure include absence of a power light on the controller, undetectable blood pressure while using the Doppler, and inability to auscultate the motor. If the MAP Is low, IV fluids would be indicated. Chest compressions are not indicated in a conscious patient. Patients with continuous flow LVADs often do not have a palpable pulse because the device is pumping constantly through the cardiac cycle; this causes aortic flow to be present during diastole, causing a reduced pulse pressure. Category: Cardiovascular emergencies/heart failure

The child of a hospital employee has died in the emergency department. The ED staff and hospital employees are visibly upset and are having difficulty coping with the child's death. Hospital administration decides to conduct a critical incident stress management (CISM) debriefing for the staff. Ideally the CISM debriefing should take place within what time frame? Within 24-72 hours

The ED nurse manager will be unable to schedule a CISM debriefing immediately following the incident. The social work department, CISM team, and chaplain will schedule the formal debriefing within 1-3 days. A formal debriefing should be scheduled within 1-3 days of the incident to allow the involved staff to debrief and to openly discuss their feelings. The sooner involved staff members are able to discuss their feelings, the sooner they can begin their grieving and healing process to cope with the events of the incidence. If greater than 72 hours have passed, those involved may have forgotten key elements they wish to discuss surrounding the event. Category: Professional Issues/Nurse/Critical Incident Stress Management

A patient with an acute mycardial infarction is being prepared for transport by ground ambulance to the nearby medical center. The patient is stable but is receiving multiple intravenous vasoactive medications. The emergency nurse should be most concerned regarding which of the following? The transport team comprises indivduals with extensive training in basic life support.

The Emergency Medical Treatment and Active Labor Act requires only that a transfer be carried out by qualified personnel using equipment required by the patient's condition. Members of the transport team must have the necessary knowledge and skills to care for the patient. The management of IV vasoactive medication is byond the scope of a basic life support provider. The nurse should not allow the transport to proceed until an advanced life support provider is available to accompany the patient. Category: Professional Issues/Patient/Transfer and stabilization

An adolescent is brought in to the ED by EMS. The patient was at a "rave" party and experienced a seizure. The patient is confused and agitated. VS are 180/98, 136, RR 26, 97%, 103.2. Which of the following would be the first nursing intervention for this patient? Place the patient in seizure precautions

The first action should always be patient safety. The patient should be in a padded bed with side rains up and the bed placed in the lowest position. Category (Pediatric) Environment and Toxicology Emergencies, and Communicable Diseases/Toxicology/Substance Abuse

The ER nurse caring for an elderly patient delegates hourly vital signs to UAP. The UAP does not report a hypotensive blood pressure to the RN and only documents it on the patient's chart. The patient suffers a poor outcome. Who is at fault for not reporting the hypotensive BP to the ER provider? The RN who delegated the task of vital signs

The RN holds the UAP responsible for the completion of the delegated task and for reporting any changes in the patient's condition. However, the RN is responsible for the delegation decision, the process, and the ongoing monitoring of the outcomes of the patient's nursing care. Category: Professional Issues/System/Delegation of tasks to assistive personnel

The ER nurse is aware that a potential sign associated with the presence of cyanide poisoning is: the odor of bitter almonds

The appearance of cherry-red skin is associated with carbon monoxide poisoning. Patients will also exhibit headache, nausea, and sob. Botulism results in the patient experiencing symmetrical descending muscular weakness. The patient may also experience blurred vision as a result of botulism. Patients with organophosphate poisoning will experience excessive secretions, in addition to feelings of confusion. The patient may also experience crackles in bilateral lung fields. Cyanide has the odor of bitter almonds. Cyanide interferes with cellular respiration and decreases use of oxygen, resulting in feelings of dizziness, bradycardia, and labored respirations. Category: Environment and toxicology emergencies, and communicable diseases/toxicology/cyanide

Which of the following patients would demonstrate the presence of delayed venous return resulting from increased intra-abdominal pressure, creating a high risk for DVT and PE? 26-year-old bariatric female

The bariatric patient has delayed venous return resulting from increased intra-abdominal pressure, creating a high risk for DVT and PE. Category: Cardiovascular emergencies/thromboembolic disease

A child is brought to the emergency department after falling through the ice while skating on a lake. On arrival, the patient's core temp is 80.2 F. The nurse would anticipate this patient to exhibit which signs or symptoms? Slow or slurred speech

The basal metabolic rate decreases by 2-3 times the normal rate in the hypothermic patient. The most evident response is seen in the CNS. In the hypothermic patient, it is expected to see a respiratory rate and effort that is decreased. This can lead to CO2 retention, hypoxia, and acidosis. Renal blood flow decreases, and the glomerular filtration rate declines in the hypothermic patient. Therefore, a decrease in urine output would be expected. Metabolism in the liver slows, so medications may last longer in the hypothermic patient. Therefore, an increased medication effect would be expected. Category (Pediatric): Enviroment and T oxicology Emergencies, and Communicable Diseases/Environment/Temperature-related emergencies

Following a MVC, an unresponsive and intubated patient is received in the ED. On assessment, a rigid and bruised abdomen is noted, and a bedside ultrasound examination identifies a ruptured bladder. Based on this information, what is the ED nurse's priority action? Establish two large-caliber IVs and begin fluid resuscitation

The bladder has an extensive blood supply that is derived from the iliac artery, and injuries resulting from a MVC are associated with pelvic fracture. For this reason, patients with a ruptured bladder are at risk for ineffective tissue perfusion and deficient fluid volume, so IV fluid resuscitation is the priority intervention to avoid the patient becoming hypovolemic. Accurate measuring of urinary output is crucial, however, initiating fluid resuscitation to avoid hypovolemia is the priority intervention. A bedside ultrasound exam will detect fluid, including blood, in the abdomen. A CT scan will most likely be required for further evaluation, but the results of the US provide sufficient information for the nurse to recognize that the patient is at risk for hypovolemia. A patient with a ruptured bladder is at an increased risk for developing peritonitis, and antibiotics are indicated; however prevention of hypovolemia is the priority intervention. Category: GI, GU, Gyn, OB emergencies/GU/Trauma

A motocyclist arrives the ED via EMS following a collision with a motor vehicle. The motorcyclist, who was thrown across the hood of the car, was helmeted and wearing leather clothing. The patient's primary survey is within normal limits. The secondary survey reveals pain and paresthesia to the right arm and right hand, with pronounced weakness but no swelling, pallor, or coolness in the extremity. The ED nurse anticipates the patient has the signs and symptoms of which of the following? Brachial plexus injury

The brachial plexus arises from the C5 to T1 spinal nerves. These nerves are responsible for supplying motor control and sensation to the arm, wrist, and hand. Injury to these spinal nerves will result in pain and parasthesia to the arm and wrist and hand weakness. Category: Maxillofacial, ocular, ortho, and wound emergencies/ortho/trauma

You are discharging a 3-year-old patient who has been diagnosed and treated for conjunctivitis. You ask the parent to repeat the instructions for care and determine the child will receive the appropriate care for when the parent states: "Everyone must practice good handwashing techniques, and my child may not attend daycare until the eye infection has resolved."

The child should not return to daycare until the redness and burning are resolved and there is no crusty discharge around the eyes upon awakening in the morning. Bacterial and viral conjunctivitis are severely contagious. Strategies to reduce transmission are rigorous handwashing, not sharing towels and washcloths or pillows, and keeping the child out of the swimming pool. Category: Maxillofacial, Ocular, Orthopedic, and Would Emergencies/Ocular/Infections

A 7-year-old suddenly develops ventricular fibrillation. The child weights 66 lbs (30 kg). Cardiopulmonary resuscitation is started immediately. What is the correct defibrillation dose for the inital shock to be used by the ED nurse? 60 joules

The child weights 30 kg. The correct initial dose is 2 joules per kg. The correct dose would be 60 joules for the initial shock and increasing to 4 joules per kg. This dose can be increased up to a maximum of 10 joules per kg. Category (pediatric): Cardiovascular emergencies/Cardiopulmonary arrest

In preparing the body of an organ donor for eye tissue donation, the emergency nurse should perform which of the following? Elevate the head of the bed 20 degrees

The eyelids should be taped shut with paper tape. Artificial tears may be instilled, but it is not required. Cool compresses or ice should be applied to the eyelids to prevent swelling. When corneas are to be donated, the head of the bed should be elevated at 20 degrees, and the eyelids should be taped shut with paper tapes. Category: Professional Issues/Patient/End-of-life issues: organ and tissue donation

A 65-year-old female reports a history of generalized anxiety disorder that is controlled with 0.5 mg of Xanax TID PRN. Which of the following patient statements requires additional follow-up and patient education by the ER nurse? I drink several glasses of wine in one setting on a regular basis.

The medication is prescribed PRN so the patient is correct to only take it PRN. Taking Xanax proactively instead of reactively is appropriate use of the medication and may help prevent dependence. Xanax is a benzodiazepine. Alcohol may intensify the effects of benzos, increasing the risk of falls and respiratory depression. The patient should be cautioned not to drink alcohol with the medication. There is no contraindication to combining dairy products with benzos. Category: Psychosocial and Medical Emergencies/Psychosocial/Anxiety/panic

The nurse is aware that the most reliable method of assessing a patient's pain is which of the following? Acknowledging the patient's self-report of pain

The most reliable means of assessing a patient's pain is based on the patient's self-report of pain. The various pain scales available provide the patient with a tool that can objectively measure the intensity of the pain experience. Category: Professional Issues/Patient/Pain management and procedural sedation

What is the best position to place a patient, in order to assess for the presence of a cardiac friction rub? Ask the patient to lean forward, then place the stethoscope at the left sternal border and listen at end-expiration.

The murmur in a patient with hypertrophic cardiomyopathy will decrease with a change from standing to squatting and peaks at midsystole, and an S4 gallop may also be present. The harsh crescendo-decrescendo murmur in a patient with aortic stenosis is best heard at the right sternal border with radiation to the neck. It has been reported that up to 85% of patients with pericarditis will have a friction rub. Although the presence of a friction rub during the initial evaluation of a patient with pericarditis is unreliable, when present, it is best heard while the patient is leaning forward, with the stethoscope placed at the left sternal boarder at end-expiration. The sound that is made when inflamed layers of the pericardium rub against each other is thought to be the cause of a friction rub. The pansystolic blowing murmur in a patient with mitral regurgitation is best heard at the apex and radiates to the axilla. Category: Cardiovascular emergencies/pericarditis

A patient who weighs 100 kg is ordered to receive tissue plasminogen activator for an acute ischemic stroke. The ED provider orders a dose of 100 mg, with 10% of the dose to be administered IVP, with the remaining dose to be administered over an hour infusion. The ED nurse verifies the weight dosing and identifies that 0.9 mg/kg is the recommended dosing for this medication in the presence of an acute ischemic stroke. The next action by the emergency nurse is to: Verify with the ED provider the medication order for this patient.

The mximum IV dose of tPA for ischemic stroke is 90 mg. The bolus is 10% of the recommended dose administered over 1 minute, and the remainder of the dose is given over 60 minutes via infusion pump. Category: Neurological Emergencies/Stroke

A patient has an elevated serum lipase level and left upper quadrant abd pain that radiates to their back. The emergency nurse recognizes these signs and symptoms as most likely being associated with which disease process? Pancreatitis

The pain associated with pancreatitis is typically felt in the LUQ of the abd and may radiate through the abd to the back. An elevated serum lipaselevel is specific to pancreatic disease or injury. Category: GI, GU, Gyn, and OB Emergencies/Gastro/Pancreatitis

An elderly patient presents to the ED after demonstrating aggressive behavior in the patient's group home residence. The ED nurse observes the patient to be pale and diaphoretic and displaying tonic-clonic movement. Which laboratory test has the greatest priority for this patient? Blood glucose level

The patient does not have a history of a seizure disorder, and therefore would not be prescribed this medication. The fastest test to obtain is a blood glucose level, which has the greatest priority for this patient. Obtaining a blood glucose level has the greatest priority for this patient. The presence of hypoglycemia is a frequent cause of seizures and acute mental status changes. A BAC is not a priority for this patient. Alcohol is a sedative, and seizures most often only occur in the presence of alcohol withdrawal. The patient does not have a history of alcoholism and did not experience seizure activity. Thiamine level may be low in patients with a history of alcoholism, but is not indicated as the patient does not have a history of alcoholism. Category: Neurological Emergencies/Seizure Disorders

The ER nurse is caring for an adult patient who was brought in by ambulance after having a tonic-clonic seizure. The patient is confused, appears anxious, and has obvious hand tremors. VS 140/90, 128 bpm RR 26, O2 98, 37.4. The patient reports that they consume alcohol on a daily basis but stopped drinking alcohol about 2 days ago. What is the priority concern for this patient? The patient is at great risk for injury.

The patient is at risk for dehydration and will likely require fluid and electrolyte replacement; however, protecting the patient from injury is the highest priority. The patient is at risk for decreased cardiac output if not treated for the alcohol withdrawal, but there are no signs and symptoms indicated an altered cardiac output. This is an appropriate concern for a patient experiencing alcohol withdrawal, but ensuring patient safety is a higher priority for the plan of care. The patient is at risk for injury because of the potential for seizures, falls, confusion, and other alcoholic withdrawal complications. The first priority should always be patient safety. Category: Environment and Toxicology Emergencies, and Communicable Diseases/Toxicology/Withdrawal syndrome

A patient presents to the ED with sudden onset lip swelling, facial edema, and throat tightness. VS are 90/60, 127 bpm, RR 22, 38.6 C. The ED nurse anticipates which of the following to be administered to this patient for their signs and symptoms? Epinephrine

The patient is experiencing an allergic reaction with possible angioedema. The administration of epinephrine promotes peripheral vasoconstriction and bronchodilation and inhibits further release of mediators immediately on entering the bloodstream. The most common cause of an allergic reaction include the administration of antibiotics, bee or wasp stings, and exposure to peanuts. Administration of high-flow oxygen to support oxygenation and treat hypoxia is important but will not act to reverse the signs and symptoms of lip swelling, facial edema, and throat tightness that the patient is experiencing. It is important to treat the patient's allergic reaction symptoms as quickly as possible to minimize the risk of complete airway compromise. Symptoms of an allergic reaction can occur quickly and progress rapidly (anaphylaxis), so prioritizing therapeutic interventions is imperative. Although corticosteroids may be administered to prevent a possible late biphasic reaction, they have no immediate effect in the treatment of an allergic reaction. Administration of albuterol will assist with treating bronchodilation and aid in the patient's breathing and increased gas exchange. Category: Psychosocial and Medical Emergencies/Medical/Allergic reactions and anaphylaxis

A patient who is 32 weeks pregnant is involved in a MVC. On arrival to the ED, the patient is complaining of severe abdominal pain. Blood is noted on the sheets around the patient's lower extremities, and on assessment, the nurse determines the patient is bleeding vaginally. High-flow oxygen is administered via face mask. The ED nurse's next action is to perform which of the following? Insert two large-caliber IVs and administer intravenous crystalloid fluids

The patient likely has experienced a placental abruption as a result of the MVC and requires the immediate administration of intravenous crystalloid fluid to prevent hypovolemia. For patients with this suspected condition, a type and screen should be drawn and sent to the lab. Maternal resuscitation is the priority. Category: GI, GU, Gyn, and OB Emergencies/OB/Abruptio placenta

An African American patient presents to emergency department triage with a complaint of chest pain, shortness of breath, fever, cough, and wheezing. The patient's medications include lisinopril, metformin, and hydroxyurea. The patient is a poor historian and is refusing to answer any questions. The ER nurse should be most concerned about which potential diagnosis for this patient. Acute chest syndrome

The patient presentation, in conjunction with their race and current medication history (hydroxyurea), is consistent with a diagnosis of sickle cell disease. Acute chest syndrome (ACS) is one of the leading causes of mortality in patients with sickle cell disease. Symptoms of ACS include chest pain, dyspnea, cough, and hypoxemia, accompanied by wheezing and pulmonary infiltrates on chest radiograph. ACS can quickly progress to acute pulmonary failure. Hydroxyurea stimlates the production of fetal hemoglobin, providing for increased oxygen carrying hemoglobin in the patient, and is effect treatment modality for patients with sickle cell disease. Category: Psychosocial and Medical Emergencies/Medical/Blood dyscrasias: Sickle cell crisis

A woman who is 10 weeks pregnant presents to the ED c/o vaginal spotting with mild abdominal cramping and is discharged to home after a diagnosis of threatened abortion is made. Which of the following statements, made by the patient, indicates a correct understanding of the discharge instructions. I will need to stay on bed rest for at least a day or two.

The patient should be instructed to count sanitary pads. Tampon use is discouraged in the presence of a threatened abortion. A patient who is experiencing a threatened abortion will be instructed to maintain bed rest for 24-48 hours or until the bleeding stops. An increase in the amount of bleeding or the passage of tissue may indicate the loss of pregnancy, and the patient should immediately contact the OB or return to the ED. Sexual intercourse should be avoided as long as the bleeding and cramping continue and the patient is on bed rest. Intercourse can worsen cramping and bleeding or introduce infection if the cervical os begins to open. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical emergencies/obstrical, threatened/spontaneous abortion

The emergency nurse is preparing to discharge a female geriatric patient who presented to the ED for severe heartburn. Medication reconciliation reveals the patient is on alendronate (Fosamax). What information should the ED nurse provide to the patient with the discharge instructions? Sit or stand upright for 30 minutes after taking alendronate.

The patient should be instructed to take the medication on an empty stomach with a full glass of water to promote absorption of the drug and to avoid eating and drinking for 30 minutes after taking it. A side effect of alendronate is esophageal irritation, so the patient must remain upright 30 minutes after taking the medication. In severe cases, the esophageal irritation can result in esophageal erosion. Alendronate is a bisphosphonate that works by inhibiting the resorption of the bone and increasing bone mass. Calcium levels need to be monitored in patients taking hormones such as calcitonin and teriparatide. Alendronate is to be taken 30 minutes before meals and should not be taken at bedtime. Category: Maxillofacial, ocular, orthopedic, and wound emergencies/orthopedic/inflammatory conditions

A patient presents to the emergency department pale and diphoretic with VS: BP 130/85 mm Hg; HR 135 bpm, SpO2 48% on room air, T 37.2 C. Lung sounds are diminished bilaterally throughout with crackles at the bases. The patient is visiting from Florida and has been in town for 4 days; the current elevation is 9500 feet. What condition should the emergency nurse be most concerned about? High-altitude pulmonary edema

The patient's lung sounds are diminished bilaterally. This assessment finding is inconsistent with the presence of a pulmonary embolism. Findings consistent with pulmonary embolism include tachypnea, tachycardia, hypotension, and dyspnea. Pneumonia is not assiciated with exposure to high altitude, and there is no recent history of a respiratory illness or fever. The patient has bilateral lung sounds throughout the lung fields. A pneumothorax would result in the patient having absent or diminished breath sounds over the area of the pneumothorax. The patient is visiting from another state with a near sea level elevation. Current lung sounds reveal diminished lung sounds throughout, with crackles present at the bases. This assessment finding is concerning because of shifting of fluid into the lungs due to maladaption to high altitude exposure (9500 feet elevation) Category: Respiratory Emergencies/Pulmonary edema

A patient presents to triage with c/o runny nose, headache, and a nonproductive cough for 3 days. the patient is able to speak without difficulty and reports a hx of moderate to severe COPD. Vital signs are 158/88, 106, RR 22, 88% RA, 98.8. The priority intervention for the emergency nurse to implement for this patient is which of the following? Apply low flow supplemental oxygen

The patient's pulse ox may be at or close to their normal baseline. However, the application of supplemental oxygen may increase their oxygenation to an acceptable level, and a full physical assessment can then proceed. Airway, breathing, and circulation should always be assessed first, along with providing supplemental oxygen. The patient's baseline oxygen may be chronically low d/t their advanced lung disease. Category: Respiratory Emergencies/COPD

A patient being evaluated in the ED is noted to have Janeway lesions, Roth's spots, and Osler's nodes along with an elevated body temperature and elevated WBC count. Patient assessment reveals the presence of several recent body piercings. The emergency nurse suspects the patient has: Endocarditis

The patient's symptoms are classic for endocarditis. Janeway lesions are petechial lesions found on the palms of the hands or soles of the feet. Osler's nodes are defined as painful fingertip lesions, and Roth's spots are retinal hemorrhages with the presence of whitish spots in the center. The patient may experience fevers along with an elevated WBC count, and recent body piercings may be a source of infections leading to endocarditis. The endocarditic infection may also spread to valve structures in the heart, resulting in permanent valvular dysfunction.

A patient presents to triage stating that they were hit in the eye with a ball while playing softball. A snellen visual acuity is performed and determines the patient has no loss of vision. While awaiting to be seen by the emergency provider, the patient begins to complain of "an aching" eye pain that is associated with sudden onset of blurred vision. Which statement made by the patient would cause the emergency nurse the greatest concern? The patient reports that everything is looking red.

The presence of a hyphema is not associated with excessive tearing, exudates, or discharge from the eye. The decreased ability to look upward with the affected eye is a symptom of entrapment of extraocular muscles associated with an orbital fracture and not the presence of a hyphema. In the presence of a hyphema (blood in the anterior chamber of the eye), some patient may report "seeing red," or blood-tinged vision from viewing the world through the layer of blood in the anterior chamber of the eye. Excessive coughing, sneezing, or continually leaning forward can result in the bleeding to resume, filling the entire anterior chamber of the eye with blood. As the outflow tracts clog with blood, anterior chamber pressure increases, which can lead to glaucoma and permanent vision loss. Secondary bleeding can occur 3-5 days following the inital injury, leading to an increased risk of vision loss. Glaucoma will present with a cloudy or hazy cornea. A cloudy appearing cornea is not associated with the presence of a hyphema. Category: Maxillofacial, Ocular, Orthopedic, and Would Emergencies/Ocular/Trauma

A construction worker is brought to the ED by their coworkers. The patient reports that while descending from a ladder, they unintentionally fired a nail gun into their right thigh. Immediately following, the patient was unable to straighten their leg, and their coworkers had to cut the patient's jean off from around the nail head. A radiograph reveals the presence of a foreign body embedded in the patient's right femur. The nurse anticipates that this injury will be managed as an open fracture

The presence of a retained foreign body may provide a nucleus of infection. Wound incision and drainage and foreign body removal are critical for healing to occur without the occurrence of infection. An injury is classified as an open fracture if a penetrating foreign body enters the bone or creates an opening in the tissue directly over the bone. Comminuted fractures occur from severe direct trauma to the bone and result in more than two bone fragments. High-pressure injection injuries from a paint or grease gun can result in the substance traveling down the fascial plane or tendon sheath, causing severe infection or permanent impairment. Immediate surgical intervention is necessary to drain the foreign substance from the tissue and preserve function. Category: Maxillofacial, ocular, ortho, and wound emergencies/ortho/fractures/dislocations

You answer a call from a primary care provider who is sending 14-year-old patient to be evaluated. The provider tells you the patient is experiencing extreme fatigue, fever, sore throat, body aches, and rash, and there is a "knot" in the left axilla. You suspect the patient may have: Infectious mononucleosis

The presence of an isolated abscess to the left axilla would not cause the other associated symptoms the patient is experiencing. An abscess could be the cause of the swelling to the left axilla and fever but would not cause a sore throat, rash, enlarged liver, or enlarged spleen. Symptoms of infectious mononucleosis include extreme fatigue, fever, sore throat, head and body aches, swollen lymph nodes in the neck and axilla, enlarged liver, enlarged spleen, and the presence of a fine red macular rash. A beta-hemolytic streptococci infection results in the symptoms associated with strep throat, which include fever, sore throat, and difficulty swallowing or talking, and would cause swelling to the cervical lymph nodes in the neck, not in the axilla. Patients with meningitis may have symptoms of fatigue, fever, rash, body aches, and headache. Meningitis generally does not cause the patient to experience a sore throat or swollen lymph nodes in the axilla. Category (Pediatric): Environment and Toxicology Emergencies, and Communicable Diseases/ Mononucleosis

A patient with a hx of chronic headaches presents to the ED with a severe headache that has grown in intesnity over the last 2 weeks. A CTA of the brain reveals no acute pathology. The pat ient typically uses nonsteroidal anti-inflammatories (NSAIDs) for pain relief and notes that over the last 2 weeks, they have had to increase the frequency of NSAID use to 4-5 days per week. The ED provider decides to place the patient on propranolol (Inderal) for prophylactic pharmacologic therapy. Which of the following statements by the patient would indicate a need for further education? I will take my propranolol as needed with the onset of a headache.

The use of a abeta-blocker is started if the patient is using a headache relief product such as acetaminophen, aspirin, and NSAIDs more than 3 days per week or having two or more disabling migraine headache symptoms per month. Prophylactic medications must be taken daily, with or without the presence of headache, to be effective. Any beta-blocker requires a 10- to 14-day taper upon discontinuing the medication. Without this taper period, the patient may experience life-threatening rebound hypertension and tachycardia. Category: Neurological Emergencies/Headache

A patient presents to the ED with chest pain and diaphoresis, and denies dyspnea. VS are 148/70, HR 72, RR 18, and 98% on RA. Breath sounds are clear and equal. The ECG shows an inferior wall ST segment elevation. You anticipate the following oxygen order. No supplemental oxygen at this time.

The use of supplemental oxygen in normoxic patients has not been established. In patients with potential coronary arter syndrome, witholding of additional supplemental oxygen should be considered for those in the prehospital or in-patient hospital setting and the ED. Supplemental oxygen has been shown to potentially extend the size of MI in the setting of normoxia. Supplemental oxygen in the setting of normoxia has not been shown to improve outcomes from MI. The higher concentration oxygen would not be indicated with an oxygen saturation of 98% on RA. Category: Cardiovascular emergenies/acute coronary syndrome

An elderly patient arrives to the ED following a fall at home. The patient's daily medication includes clopidogrel (Plavix) 300 mg daily. The patient is diagnosed with an intracranial bleed. The ED nurse anticipates which of the following actions to be taken? Discontinue the Plavix immediately

There is no antidote for the presence of an excessive amount of Plavix in the blood stream. Vitamin K - Warfarin Protamine sulfate - heparin Category (Geriatric): Psychosocial and Medical Emergencies/Medical/Blood dyscrasias: other coagulopathies

The nurse ensures that the mechanically ventilated patient is placed in a semirecumbent position to: prevent aspiration

This position can increase the chance of a decubitis pressure ulcer. When clinically indicated, a patient should be turned at least every 2 hours to prevent decubitus pressure ulcers from occurring. A patient may be more comfortable sitting up in bed; however, the reason to keep the patient in a semirecumbent position is to prevent gastroesophageal reflux, which can cause ventilator-associated pneumonia, resulting in morbidity and mortality. Oral care is important to prevent ventilator-associated pneumonia and can be completed with the patient supine if necessary. An intubated patient who is supine is more likely to experience gastroesophageal reflux of stomach contents that can result in aspiration pneumonia. A semirecumbent position has been shown to prevent ventilator-associated pneumonia when the head and torso are at an angle of 30-45 degrees. Category: Respiratory emergencies/infections

What diagnostic test should the ED nurse anticipate to be performed in a patient with bipolar disorder who has been receiving antipsychotic medications for treatment of acute mania? 12-lead EKG

Though clozapine, an atypical or second-generation antipsychotic, has the risk of causing neutropenia, this is not associated with all antipsychotics. Performing a CBC would not be the most important diagnostic test will in the ED. Antipsychotic medications are not commonly associated with hepatic injury. Obtaining a 12-lead EKG and continuous cardiac monitoring is more important. Most antipsychotic medications can result in prolongation of the QT interval, which can lead to a life-threatening dysrhythmia. Category: Psychosocial and Medical Emergencies/Psychosocial/Bipolar Disorder

A patient presents to triage complaining of pain in the right distal forearm after falling onto their outstretched arm. There is an obvious deformity above the patient's right wrist. Right radial pulse is present and color and sensation are intact distally, however, the patient is unable to sustain a wrist grip. The emergency nurse is aware that it is best to immobilize the forearm using a padded rigid long arm splint

Traction splints are used for actual or potential femur or proximal tibial fractures and would not be indicated for an upper extremity injury. Splinting of the extremity is indicated when there is evidence of deformity, pain, bony crepitus, edema, ecchymosis, open soft tissue injury, paralysis, or paresthesia. Always immobilize joints above and below a suspected fracture site. Soft splints include pillows and slings and could be an option if a rigid splint is not available. The presence of an obvious deformity makes the use of a rigid splint the best choice of treatment for this patient. Application of ice and elevation are indicated to reduce swelling and pain but will not provide immobilization of the extremity. A rigid splint is the best choice for the immediate treatment of this patient. Category: Maxillofacial, Ocular, Ortho and Wound Emergencies/Ortho/Fractures/Dislocations

A patient presents to the ED with symptoms of left lower quadrant abd cramping with frequent episodes of blood and mucus-containing diarrhea. The symptoms have been present for the past 3 weeks and the patient has noticed a recent weight loss. The ED nurse anticipates the patient will most likely need further evaluation for which disorder? Ulcerative Colitis

Ulcerative colitis is an inflammatory condition that affects the large intestine. LLQ abd pain with bloody diarrhea, a result of the effects of the disease on the lining of the colon, are hallmark signs of the disease. Patients can pass between 10-20 liquid stools per day. Additional symptoms include weight loss, fever, and tachycardia. A change in bowel habits and weight loss, which may include constipation and/or diarrhea, are primary symptoms associated with colon-rectal cancers; however, the diarrhea associated with colon cancer is less frequent than that with ulcerative colitis and does not contain mucus. Abd cramping with colon cancer is more likely to be associated with a cancerous lesion causing a bowel obstruction. Infectious diarrhea, such as that caused by a salmonella exposure, is characterized by cramping, colicky abdominal pain, and bloody diarrhea. These symptoms usually resolve within 24 hours. Crohns' disease can be characterized by cramping abd pain, which is more likely to be in the RLQ. Category: GI, GU, Gyn, and OB Emergencies/GI/Inflammatory bowel disease

A patient has sustained a stab wound to the left parasternal anterior chest. Emergency medical services treatment has included intubation and IV therapy with crystalloid solution. The patient exhibited vital signs during transport, however, as the patient is being wheeled into the trauma room, pulses are no longer detected. Cardiopulmonary resuscitation is initiated. Breath sounds are present bilaterally. The nurse anticipates the following procedure to be immediately performed. Open thoracotomy

Ultrasound at the bedside may be helpful with diagnosis of life-threatening injuries such as pericardial tamponade but will only delay the initiation of potentially life-saving open ED thoracotomy (EDT). A chest radiograph may help define the presence of pneumothorax, hemothorax, or retained foreign objects but delays the initiation of an open EDT. Patients with low velocity penetrating chest trauma with loss of signs of life on or just before arrival to the ED have the best chance of survival with an open EDT. Needle pericardiocentesis is often ineffective in relieving traumatic pericardial tamponade and delays the initiation of an open EDT. Category: Cardiovascular Emergencies/Trauma

The ED nurse is preparing to discharge a patient who has received treatment to close a facial laceration. the nurse recognizes the patient's understanding of the discharge instructions when stating the following: I need to place a thin layer of antibiotic ointment over the sutures daily.

Uncomplicated wounds in a healthy individual do not usually require systemic antibiotics. The application of antibiotic ointment will help to prevent wound infection. Staple wound closers are limited to earea where a scar will not be apparent, and therefore are not indicated for facil wounds. Facial sutures are typically removed in 3-5 days. Sutures over joitns require 14 days to heal before removal. Category: Maxillofacial, ocular, ortho, and wound emergencies/wound/infections

A child presents to the ED after choking on a chicken bone. The patient's airway is not obstructed, but swallowing is difficult, and the child is consistently drooling. The nurse anticipates which diagnostic test to be performed initially? Chest radiograph

Unless the object can be observed in the upper airway, a chest radiograph is best to determine the object's location in the upper GI system. Ultrasound is a quick and accurate means to evaluate organ structure and identify vascular injuries, but is not useful to evaluate the presence of a foreign body in the upper airway or GI system. The child's respiratory status does not require endotracheal intubation, so an end-tidal CO2 measurement would not provide any useful information. Once the foreign body is located, direct laryngoscopy can be used tovisualize and remove the foreign body, but a radiograph will initially define the existence and location of the object. Category (pediatric) GI, GU, Gyn, and OB emergencies/GI/Foreign bodies

An unresponsive pt involved in a high-speed MVC with multiple facial injuries arrives in the ED via EMA. Because of the presence of numerous facial injuries, it is determined that the patient is at risk for an upper airway obstruction. Which of the following maneuvers is best to initiate to prevent an upper airway obstruction? Place airway adjunct into the patient

Up to 10% of patients with significant blunt force facial injuries will also have the presence of a corresponding cervical spine injury; therefore, cervical spine immobilization should be maintained until the presence of a cervical injury can be ruled out. A nasopharyngeal airway can be placed in patients who are either conscious or unconscious. An oropharyngeal airway is only used in patients who have an absent gag reflex. These devices can maintain an open airway until further interventions can be performed, such as endotracheal intubation or cricothyroidotomy to maintain airway patency. Placing the patient into a left lateral position should not be performed until the presence or absence of a cervical spine injury can be determined.

An unresponsive trauma patient is brought to the emergency department by ambulance. There are no family members present, and no contact information is available for the patient's family. It is appropriate for ED personnel to treat this patient based on which type of consent? Implied consent

When a patient is unconscious or unable to provide verbal consent, no family members are present, and immediate interventions are necessary to save the patient's life and/or limb, the physician is obligated to act on the patient's behalf. The action is referred to as implied consent. If the patient was alert and oriented, they could have provided expressed consent. Expressed consent occurs when a patient voluntarily consents to medical treatment and is predicated on the patient's mental capacity. Because the patient is unresponsive and in a life-threatening situation, treatment for this patient is based on implied consent. Involuntary consent is indicated when an incompetent individual refuses necessary medical treatment, and the patient requires immediate intervention. Provided by the physician, informed consent describes the procedure being performed, the alternatives to the procedure, and the risks and benefits associated with the procedure. Informed consent is based on the patient's understanding of the risks, benefits, and alternatives to any therapy or procedures. Because the patient is unresponsive, they cannot be provided with the description, alternatives, risks, and benefits of any therapy or procedures. Category: Professional Issues/System/Patient consent for treatment