Page 1
CEN EXAM 1 STUDY GUIDE ACTUAL EXAM
Q&A TESTED AND APPROVED NEWLY
MODIFIED EXAM
An elderly patient has recently taken a large dose of imipramine (Tofranil) in an apparent
suicide attempt. He is confused and disoriented, hypotensive, and tachycardic with flushed
skin and wide pupils. While being brought in by paramedics, he has a seizure. An ECG shows
a sinus tachycardia with a prolonged QRS complex and QT-interval and T-wave
abnormalities. Which of the following pharmacologic agents would NOT be appropriate?
a.lorazepam (Ativan)
b.sodium bicarbonate
c.phenytoin (Dilantin)
d.activated charcoal and sorbitol -- ANSWER--C: Overdose of tricyclic antidepressants, often
by elderly patients with suicidal intent, is less common now since the advent of SSRI drugs
for depression but is still a fairly frequent medical emergency. More common is CNS
dysfunction ranging from disorientation and confusion to seizures and frank coma;
anticholinergic effects including flushed skin, dry mucous membranes, and mydriasis; and
cardiac effects including conduction abnormalities and ventricular tachycardia. Phenytoin is
contraindicated for seizures in these patients because it has sodium channel blocking activity
and may worsen arrhythmias. The drugs are very well absorbed by activated charcoal; the
combination of activated charcoal with sorbitol to overcome the anticholinergics effects on
the bowel is useful. Sodium bicarbonate raises the blood pH and lowers the free drug
concentration, improving some of the ECG abnormalities.
Which of the following is NOT recommended for routine hemodynamic monitoring of
patients in shock?
a.pulmonary artery catheter
Page 1 of 93
, Page 2
b.central venous pressure
c.pulse oximetry
d.superior vena cava oxygen saturation (ScvO2) -- ANSWER--A: While observation of the
patient's heart and respiratory rates, mental status, and adequacy of peripheral circulation are
clinical indicators of shock, several invasive and noninvasive methods for following
effectiveness of treatment are available. Pulse oximetry is a simple and noninvasive technique
to measure peripheral oxygen saturation but is subject to limitations in estimating circulation
and hypoxia, especially with use of vasoactive medications or hypothermia. Central venous
pressure is a useful measure of circulating volume, cardiac performance, and vascular tone.
Values under the normal range of 4 to 10 cm H2O indicate a low circulating volume while
values above this range may indicate excessive fluid administration, pulmonary edema, or
vascular obstruction. ScvO2 is measured from a catheter in the superior vena cava and a
value of 70% is used to guide therapy even if clinical signs show improvement. Pulmonary
artery catheters (e.g., Swan-Ganz) are not recommended for routine hemodynamic
monitoring.
A patient presents with a history of nausea, vomiting, and diarrhea for several days after a
Caribbean cruise. In the emergency department, she is weak, moderately hypotensive, and
dehydrated. An ECG shows bradycardia, mild ST depression, and a U wave with some
ventricular ectopic beats. What is the most likely electrolyte abnormality?
a.hypomagnesemia
b.hyperkalemia
c.Hypokalemia
d.hypocalcemia -- ANSWER--C: Hypokalemia (potassium lower than 3.5 mEq/L) may result
from gastrointestinal or renal loss, or from transfer from extracellular fluid to intracellular
fluid. Drugs such as aldosterone, insulin, and beta2-agonists promote the latter.
Gastrointestinal loss is the most likely cause in this patient and hypokalemia may be a feature
Page 2 of 93
, Page 3
of traveler's gastroenteritis. Renal loss occurs with diuretics or kidney disease and low
potassium may be a feature of diabetic ketoacidosis or excess steroids. The ECG findings
described are typical of low potassium but do not necessarily correlate with the degree.
Potassium administration should be through a large bore or central venous catheter (it is
locally irritating) by an infusion pump at 40 mEq/L not to exceed 10 to 20 mEq per hour. For
severe hypokalemia, a 5 to 10 mEq bolus may be given but serial potassium and cardiac
monitoring is required to avoid hyperkalemia, ventricular dysrhythmias, and death. Low
serum magnesium levels may accompany hypokalemia and should be checked.
Which blood test may indicate infection or inflammation and would need to be used as part of
the clinical picture with diagnosing and treating abdominal pain?
a. white blood cell (WBC) count of 5.0
b. hematocrit (HCT) of 45
c. WBC count of 28.0
d. blood sugar (BS) of 74 -- ANSWER--C: An elevated WBC count would be indicative of
infection or inflammation. The WBC count of 5.0 is normal. The HCT and BS levels listed
would also be considered within normal limits.
A 7-year-old child is brought to the emergency department after multiple bee stings about 30
minutes previously. He complains of itching, swollen lips, and difficulty breathing. Wheezing
and stridor are heard. What is the most immediate treatment required?
a. epinephrine 0.1 mg intramuscularly
b. intravenous corticosteroid
c. intravenous antihistamine
d. broad-spectrum antibiotic -- ANSWER--Answer: A
, Page 4
The clinical picture of this patient is that of an anaphylactic reaction to bee stings which is
potentially life-threatening. The onset of symptoms within 1 hour after exposure to the
allergen is particularly worrisome as are the laryngeal and pulmonary signs. The airway must
be established with intubation often necessary; high-flow oxygen, cardiac monitoring, and
intravenous fluids are basics. Epinephrine given intramuscularly is the most rapidly acting
agent and should be given as soon as possible after the diagnosis of anaphylaxis and every 5
to 15 minutes thereafter as needed. Steroids and antihistamines are slower acting than
epinephrine but are often given to alleviate itching, angioedema, and hives. There is no
indication for antibiotics in this clinical situation unless further signs and symptoms develop.
After an auto accident, x-rays of the patient's leg show a transverse fracture of the midfemur
with several bone fragments surrounding the fracture site. The skin of the leg is intact. This
type fracture is called:
a.compression fracture
b.comminuted fracture
c.avulsion fracture
d.open fracture -- ANSWER--Answer: B
A fracture is a break or disruption in a bone, generally divided into closed (no break in the
skin) and open (protrusion of the bone through the skin). Fractures may take different
anatomic patterns, depending on the bone location, the nature of the trauma and the bone
density (may be diminished with osteoporosis). Compression fractures are most common in
the spine in which a fracture of one or more vertebral bodies leads to a collapse of the spine
at that location. An avulsion fracture reflects a forceful contraction of muscle mass, which
pulls a bone fragment to break away at the tendon's insertion site. This type of fracture is
often seen with severe joint strains. This patient has a comminuted fracture in which the
trauma causes more than two separated portions of the bone. Often, several small bony
fragments are seen at the site of the break.
CEN EXAM 1 STUDY GUIDE ACTUAL EXAM
Q&A TESTED AND APPROVED NEWLY
MODIFIED EXAM
An elderly patient has recently taken a large dose of imipramine (Tofranil) in an apparent
suicide attempt. He is confused and disoriented, hypotensive, and tachycardic with flushed
skin and wide pupils. While being brought in by paramedics, he has a seizure. An ECG shows
a sinus tachycardia with a prolonged QRS complex and QT-interval and T-wave
abnormalities. Which of the following pharmacologic agents would NOT be appropriate?
a.lorazepam (Ativan)
b.sodium bicarbonate
c.phenytoin (Dilantin)
d.activated charcoal and sorbitol -- ANSWER--C: Overdose of tricyclic antidepressants, often
by elderly patients with suicidal intent, is less common now since the advent of SSRI drugs
for depression but is still a fairly frequent medical emergency. More common is CNS
dysfunction ranging from disorientation and confusion to seizures and frank coma;
anticholinergic effects including flushed skin, dry mucous membranes, and mydriasis; and
cardiac effects including conduction abnormalities and ventricular tachycardia. Phenytoin is
contraindicated for seizures in these patients because it has sodium channel blocking activity
and may worsen arrhythmias. The drugs are very well absorbed by activated charcoal; the
combination of activated charcoal with sorbitol to overcome the anticholinergics effects on
the bowel is useful. Sodium bicarbonate raises the blood pH and lowers the free drug
concentration, improving some of the ECG abnormalities.
Which of the following is NOT recommended for routine hemodynamic monitoring of
patients in shock?
a.pulmonary artery catheter
Page 1 of 93
, Page 2
b.central venous pressure
c.pulse oximetry
d.superior vena cava oxygen saturation (ScvO2) -- ANSWER--A: While observation of the
patient's heart and respiratory rates, mental status, and adequacy of peripheral circulation are
clinical indicators of shock, several invasive and noninvasive methods for following
effectiveness of treatment are available. Pulse oximetry is a simple and noninvasive technique
to measure peripheral oxygen saturation but is subject to limitations in estimating circulation
and hypoxia, especially with use of vasoactive medications or hypothermia. Central venous
pressure is a useful measure of circulating volume, cardiac performance, and vascular tone.
Values under the normal range of 4 to 10 cm H2O indicate a low circulating volume while
values above this range may indicate excessive fluid administration, pulmonary edema, or
vascular obstruction. ScvO2 is measured from a catheter in the superior vena cava and a
value of 70% is used to guide therapy even if clinical signs show improvement. Pulmonary
artery catheters (e.g., Swan-Ganz) are not recommended for routine hemodynamic
monitoring.
A patient presents with a history of nausea, vomiting, and diarrhea for several days after a
Caribbean cruise. In the emergency department, she is weak, moderately hypotensive, and
dehydrated. An ECG shows bradycardia, mild ST depression, and a U wave with some
ventricular ectopic beats. What is the most likely electrolyte abnormality?
a.hypomagnesemia
b.hyperkalemia
c.Hypokalemia
d.hypocalcemia -- ANSWER--C: Hypokalemia (potassium lower than 3.5 mEq/L) may result
from gastrointestinal or renal loss, or from transfer from extracellular fluid to intracellular
fluid. Drugs such as aldosterone, insulin, and beta2-agonists promote the latter.
Gastrointestinal loss is the most likely cause in this patient and hypokalemia may be a feature
Page 2 of 93
, Page 3
of traveler's gastroenteritis. Renal loss occurs with diuretics or kidney disease and low
potassium may be a feature of diabetic ketoacidosis or excess steroids. The ECG findings
described are typical of low potassium but do not necessarily correlate with the degree.
Potassium administration should be through a large bore or central venous catheter (it is
locally irritating) by an infusion pump at 40 mEq/L not to exceed 10 to 20 mEq per hour. For
severe hypokalemia, a 5 to 10 mEq bolus may be given but serial potassium and cardiac
monitoring is required to avoid hyperkalemia, ventricular dysrhythmias, and death. Low
serum magnesium levels may accompany hypokalemia and should be checked.
Which blood test may indicate infection or inflammation and would need to be used as part of
the clinical picture with diagnosing and treating abdominal pain?
a. white blood cell (WBC) count of 5.0
b. hematocrit (HCT) of 45
c. WBC count of 28.0
d. blood sugar (BS) of 74 -- ANSWER--C: An elevated WBC count would be indicative of
infection or inflammation. The WBC count of 5.0 is normal. The HCT and BS levels listed
would also be considered within normal limits.
A 7-year-old child is brought to the emergency department after multiple bee stings about 30
minutes previously. He complains of itching, swollen lips, and difficulty breathing. Wheezing
and stridor are heard. What is the most immediate treatment required?
a. epinephrine 0.1 mg intramuscularly
b. intravenous corticosteroid
c. intravenous antihistamine
d. broad-spectrum antibiotic -- ANSWER--Answer: A
, Page 4
The clinical picture of this patient is that of an anaphylactic reaction to bee stings which is
potentially life-threatening. The onset of symptoms within 1 hour after exposure to the
allergen is particularly worrisome as are the laryngeal and pulmonary signs. The airway must
be established with intubation often necessary; high-flow oxygen, cardiac monitoring, and
intravenous fluids are basics. Epinephrine given intramuscularly is the most rapidly acting
agent and should be given as soon as possible after the diagnosis of anaphylaxis and every 5
to 15 minutes thereafter as needed. Steroids and antihistamines are slower acting than
epinephrine but are often given to alleviate itching, angioedema, and hives. There is no
indication for antibiotics in this clinical situation unless further signs and symptoms develop.
After an auto accident, x-rays of the patient's leg show a transverse fracture of the midfemur
with several bone fragments surrounding the fracture site. The skin of the leg is intact. This
type fracture is called:
a.compression fracture
b.comminuted fracture
c.avulsion fracture
d.open fracture -- ANSWER--Answer: B
A fracture is a break or disruption in a bone, generally divided into closed (no break in the
skin) and open (protrusion of the bone through the skin). Fractures may take different
anatomic patterns, depending on the bone location, the nature of the trauma and the bone
density (may be diminished with osteoporosis). Compression fractures are most common in
the spine in which a fracture of one or more vertebral bodies leads to a collapse of the spine
at that location. An avulsion fracture reflects a forceful contraction of muscle mass, which
pulls a bone fragment to break away at the tendon's insertion site. This type of fracture is
often seen with severe joint strains. This patient has a comminuted fracture in which the
trauma causes more than two separated portions of the bone. Often, several small bony
fragments are seen at the site of the break.
