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The nurse is caring for a patient who has a high fever, central nervous system dysfunction
and tachycardia. The nurse should recognize that the patient may be experiencing
A. myxedema crisis.
B. Beck's triad.
C. thyroid storm.
D. hyperosmolar hyperglycemic nonketotic syndrome (HHNS). - ANSWER C. Thyroid
storm
Which of the following assessment findings associated with a skull fracture indicate the need
for further intervention?
A. otorrhea, nausea, and vomiting
B. decreasing level of consciousness and restlessness
C. early evidence of periorbital ecchymosis and photophobia
D. rhinorrhea and headache or dizziness - ANSWER B. decreasing level of
consciousness and restlessness
Upon initial assessment of a male patient involved in a motor vehicle crash, the nurse
observes bruises in various stages of healing to his torso. He denies any medical history.
When asked about the bruising, the patient avoids eye contact, states that he fell yesterday,
and asks if his male partner has arrived to the ED. The nurse suspects:
A. the patient may have undiagnosed coagulopathy.
B. the bruising was sustained during the motor vehicle crash.
1
,C. the patient may be a victim of domestic violence.
D. the bruising is a result of the stated fall. - ANSWER C. the patient may be a victim
of domestic violence.
The nurse is caring for a patient who became unresponsive after diving head-first into a
shallow pool. The patient is experiencing refractory hypotension. The nurse should prepare
for the administration of
a. lactated Ringers.
b. norepinephrine.
c. normal saline.
d. epinephrine. - ANSWER b. norepinephrine
A 3-year-old child who has acute respiratory distress is admitted to the emergency
department. The child is sitting forward and drooling, and the neck is extended. These
findings support the diagnosis of
A. epiglottitis.
B. bronchiolitis.
C. croup.
D. aspiration of a foreign body. - ANSWER A. epiglottitis
The nurse understands that adenosine is administered
A. IV push over 1-2 seconds.
B. as a bolus over 10-15 minutes.
C. as a bolus over 1 hour.
D. IV push over 1-2 minutes. - ANSWER A. IV push over 1-2 seconds.
A man who briefly lost consciousness after a motor vehicle crash is alert and oriented upon
arrival at the emergency department. The patient states that he is fine except for an
abrasion where his head hit the door frame of the vehicle. The patient complains of blurred
vision 1 hour later. The nurse should FIRST
2
,A. repeat the neurologic assessment.
B. obtain orthostatic vital signs.
C. assess visual acuity.
D. obtain blood glucose measurement. - ANSWER A. repeat the neurologic
assessment.
After a non-traumatic resuscitation, the patient has a perfusing ECG rhythm and a stable
blood pressure, but the patient remains comatose. The nurse should NEXT prepare for
A. initiation of targeted temperature management.
B. initiation of stroke protocol.
C. transport to the cardiac catheterization lab.
D. transport to the neurovascular suite. - ANSWER A. initiation of targeted
temperature management.
After a patient has an episode of violent behavior in the waiting room, an important
intervention is to
A. tell the patient to get himself under control.
B. instruct the patient to be quiet and speak only when spoken to.
C. allow the patient to go home as soon as possible.
D. encourage the patient to verbalize his feelings about the situation. - ANSWER D.
encourage the patient to verbalize his feelings about the situation.
The nurse is caring for a patient with complaints of progressive, ascending paralysis starting
from the feet and progressing over the last week. It would be a PRIORITY for the nurse to
monitor the patient's
A. pupillary response.
B. peripheral pulses.
C. respiratory status.
D. Blood glucose - ANSWER C. respiratory status.
3
, A patient with acute cocaine intoxication should be expected to have
A. rising core body temperature.
B. drowsiness.
C.flaccid extremities.
D. first-degree AV block. - ANSWER A. rising core body temperature.
Which of the following ocular conditions requires the HIGHEST treatment priority?
A. periorbital hematoma with edema
B. hyphema following a blow to the eye
C. a retained metal foreign body
D. sudden, painless loss of vision in one eye - ANSWER D. sudden, painless loss of
vision in one eye
A patient presents with complaints of fatigue and exhaustion, and reveals a recent move
across country for a new high stress job. The patient admits to recent increase in alcohol
consumption. The nurse suspects the patient is experiencing:
A. schizophrenia.
B. situational crisis.
C. psychotic depression.
D. acute mania. - ANSWER B. situational crisis.
The nurse is caring for a patient who suddenly stops breathing and is in ventricular
fibrillation. The nurse should FIRST
A. perform synchronized cardioversion at 200 joules.
B. provide oxygen and ventilation via a bag-mask device.
C. start chest compressions.
D. administer 1 mg of intravenous epinephrine. - ANSWER C. start chest
compressions.
4
The nurse is caring for a patient who has a high fever, central nervous system dysfunction
and tachycardia. The nurse should recognize that the patient may be experiencing
A. myxedema crisis.
B. Beck's triad.
C. thyroid storm.
D. hyperosmolar hyperglycemic nonketotic syndrome (HHNS). - ANSWER C. Thyroid
storm
Which of the following assessment findings associated with a skull fracture indicate the need
for further intervention?
A. otorrhea, nausea, and vomiting
B. decreasing level of consciousness and restlessness
C. early evidence of periorbital ecchymosis and photophobia
D. rhinorrhea and headache or dizziness - ANSWER B. decreasing level of
consciousness and restlessness
Upon initial assessment of a male patient involved in a motor vehicle crash, the nurse
observes bruises in various stages of healing to his torso. He denies any medical history.
When asked about the bruising, the patient avoids eye contact, states that he fell yesterday,
and asks if his male partner has arrived to the ED. The nurse suspects:
A. the patient may have undiagnosed coagulopathy.
B. the bruising was sustained during the motor vehicle crash.
1
,C. the patient may be a victim of domestic violence.
D. the bruising is a result of the stated fall. - ANSWER C. the patient may be a victim
of domestic violence.
The nurse is caring for a patient who became unresponsive after diving head-first into a
shallow pool. The patient is experiencing refractory hypotension. The nurse should prepare
for the administration of
a. lactated Ringers.
b. norepinephrine.
c. normal saline.
d. epinephrine. - ANSWER b. norepinephrine
A 3-year-old child who has acute respiratory distress is admitted to the emergency
department. The child is sitting forward and drooling, and the neck is extended. These
findings support the diagnosis of
A. epiglottitis.
B. bronchiolitis.
C. croup.
D. aspiration of a foreign body. - ANSWER A. epiglottitis
The nurse understands that adenosine is administered
A. IV push over 1-2 seconds.
B. as a bolus over 10-15 minutes.
C. as a bolus over 1 hour.
D. IV push over 1-2 minutes. - ANSWER A. IV push over 1-2 seconds.
A man who briefly lost consciousness after a motor vehicle crash is alert and oriented upon
arrival at the emergency department. The patient states that he is fine except for an
abrasion where his head hit the door frame of the vehicle. The patient complains of blurred
vision 1 hour later. The nurse should FIRST
2
,A. repeat the neurologic assessment.
B. obtain orthostatic vital signs.
C. assess visual acuity.
D. obtain blood glucose measurement. - ANSWER A. repeat the neurologic
assessment.
After a non-traumatic resuscitation, the patient has a perfusing ECG rhythm and a stable
blood pressure, but the patient remains comatose. The nurse should NEXT prepare for
A. initiation of targeted temperature management.
B. initiation of stroke protocol.
C. transport to the cardiac catheterization lab.
D. transport to the neurovascular suite. - ANSWER A. initiation of targeted
temperature management.
After a patient has an episode of violent behavior in the waiting room, an important
intervention is to
A. tell the patient to get himself under control.
B. instruct the patient to be quiet and speak only when spoken to.
C. allow the patient to go home as soon as possible.
D. encourage the patient to verbalize his feelings about the situation. - ANSWER D.
encourage the patient to verbalize his feelings about the situation.
The nurse is caring for a patient with complaints of progressive, ascending paralysis starting
from the feet and progressing over the last week. It would be a PRIORITY for the nurse to
monitor the patient's
A. pupillary response.
B. peripheral pulses.
C. respiratory status.
D. Blood glucose - ANSWER C. respiratory status.
3
, A patient with acute cocaine intoxication should be expected to have
A. rising core body temperature.
B. drowsiness.
C.flaccid extremities.
D. first-degree AV block. - ANSWER A. rising core body temperature.
Which of the following ocular conditions requires the HIGHEST treatment priority?
A. periorbital hematoma with edema
B. hyphema following a blow to the eye
C. a retained metal foreign body
D. sudden, painless loss of vision in one eye - ANSWER D. sudden, painless loss of
vision in one eye
A patient presents with complaints of fatigue and exhaustion, and reveals a recent move
across country for a new high stress job. The patient admits to recent increase in alcohol
consumption. The nurse suspects the patient is experiencing:
A. schizophrenia.
B. situational crisis.
C. psychotic depression.
D. acute mania. - ANSWER B. situational crisis.
The nurse is caring for a patient who suddenly stops breathing and is in ventricular
fibrillation. The nurse should FIRST
A. perform synchronized cardioversion at 200 joules.
B. provide oxygen and ventilation via a bag-mask device.
C. start chest compressions.
D. administer 1 mg of intravenous epinephrine. - ANSWER C. start chest
compressions.
4
