ENPC 4th Edition: Practice Test questions and answers

ENPC 4th Edition: Practice Test questions and answers 1. A preschooler has a small laceration that requires 2 stitches. The nurse covers the wound with a bandage knowing that it will comfort the child to have it covered. What is the developmental reason for this intervention? A.) Preschoolers are magical thinkers and imagine bandages keep their insides from coming out. B.) Preschoolers fear physical disability and believe a bandage will prevent disability. C.) Preschoolers explore orally and will likely chew or suck on the stitches if left uncovered. D.) Preschoolers are concerned with body image and don't want to appear different than peers. A.) Preschoolers are magical thinkers and imagine bandages keep their insides from coming out. Rationale: Preschoolers are magical and illogical thinkers and have difficulty distinguishing fantasy from reality. They have misconceptions about illness, injury, and bodily functions. For example, they perceive that if their skin is cut, they fear their insides will leak out. Covering a wound with a bandage helps them with this fear. 2. 7-month-old presents to the emergency department with a complaint of fever. Assessment reveals a patent airway and slight cyanosis around his lips and nail beds. He is alert and interactive. His vital signs are 38.5 C (101.3F), HR 134, RR 32, BP 78/54 mm Hg, and Spo2 84%. The nurse notes a healed surgical scar on his chest. Based on this assessment, what is the nurse's priority? A.) Administer ibuprofen to treat the fever. B.) Begin oxygen via a nonrebreather mask. C.) Obtain a surgical history. D.) Ask if the Spo2 is normal for him. D.) Ask if the Spo2 is normal for him. Rationale: Children with special healthcare needs may present differently than other children, but these differences may be normal. The surgical scar on the chest is likely from a congenital heart defect repair. The mother's chief complaint is the fever, not the color, pulse oximetry, or the respiratory distress. This may be because these aspects of his assessment are normal. The intact mental status is also a sign that he has adapted to lowers oxygen saturation's. The child's baseline must come from the caregiver before any intervention. 3. An 11-year-old presents to the emergency department with a complaint of hitting his head while playing soccer. The nurse enters the room and performs an across-the-room assessment. He is staring at the wall. He has no increased work of breathing, and his color is pink. Using the pediatric assessment triangle (PAT), what classification will the nurse assign? A.) Well Rationale: In using the PAT, there is not a Well category. A child may appear well and without disruption in any of the three components of the PAT but is still designated sick. All pediatric patients presenting to the emergency department are considered sick simply based on the fact that the caregiver was concerned enough to bring the child to the emergency department (p. 54). B.) Sick Rationale: If there is no disruption in any of the three components of the PAT, a pediatric patient is considered sick. This child has an abnormality in one of the three. He is staring at the wall, which is a disruption in the general appearance component (p. 54). C.) Sicker Rationale: This child has a disruption in one of the three components of the PAT. He is staring at the wall, which is a disruption in the general appearance component. It may be that he is anxious and fearful about the experience, but it could be a result of the head injury. More assessment is required (p. 54). D.) Sickest Rationale: If there are disruptions in two or more of the three components of the PAT, a pediatric patient is considered sickest and needs immediate evaluation and intervention. This child has an abnormality in one of the three components (p. 54). C.) Sicker Rationale: This child has a disruption in one of the three components of the PAT. He is staring at the wall, which is a disruption in the general appearance component. It may be that he is anxious and fearful about the experience, but it could be a result of the head injury. More assessment is required (p. 54). 4. The pediatric prioritization process components include the focused assessment, focused history, acuity rating decision and: A.) the pediatric assessment triangle (PAT). Rationale: The four components of the pediatric prioritization process include the pediatric assessment triangle (PAT), the focused assessment (objective data), the focused history (subjective data), and the assignment of the triage acuity rating. These components ensure enough information is rapidly gathered and used to provide appropriate care and timely interventions for pediatric patients (p. 52). B.) developmental characteristics. Rationale: Developmental characteristics are incorporated into each component of the pediatric prioritization process but do not constitute a separate element (p. 52). C.) head-to-toe assessment. Rationale: The head-to-toe assessment is part of the focused assessment but not a separate element (p. 52). D.) life-saving interventions. Rationale: Life-saving interventions should be performed at any point throughout the prioritization process as life threats are identified (p. 52) A.) The pediatric assessment triangle (PAT). Rationale: The four components of the pediatric prioritization process include the pediatric assessment triangle (PAT), the focused assessment (objective data), the focused history (subjective data), and the assignment of the triage acuity rating. These components ensure enough information is rapidly gathered and used to provide appropriate care and timely interventions for pediatric patients (p. 52). 5. A 2-year-old is brought to the emergency department by her father when he found her face down in the pool. She remains unresponsive and is breathing shallowly and slowly. Her color is pale. What is the priority? A.) Administer 100% oxygen Rationale: The primary assessment in a trauma patient begins with immobilization of the cervical spine while opening the airway. The remainder of the primary assessment interventions including oxygenation is performed after cervical spinal immobilization (p. 64). B.) Immobilize the cervical spine Rationale: Any unresponsive child found in a pool must be assumed to be a trauma patient and with a cervical spinal injury until proven otherwise. The primary assessment in a trauma patient begins with immobilization of the cervical spine while opening the airway. The remainder of the primary assessment interventions, including inserting an airway, oxygenation, and ventilation, is performed after cervical spinal immobilization (p. 64). C.) Begin bag-mask ventilation Rationale: The primary assessment in a trauma patient begins with immobilization of the cervical spine while opening the airway. The remainder of the primary assessment interventions, including ventilation, is performed after cervical spinal immobilization (p. 64). D.) Insert an oral airway Rationale: The primary assessment in a trauma patient begins with immobilization of the cervical spine while opening the airway. The remainder of the primary assessment interventions, including inserting an airway, if needed, is performed after cervical spinal immobilization (p. 64). B.) Immobilize the cervical spine. Rationale: Any unresponsive child found in a pool must be assumed to be a trauma patient and with a cervical spinal injury until proven otherwise. The primary assessment in a trauma patient begins with immobilization of the cervical spine while opening the airway. The remainder of the primary assessment interventions, including inserting an airway, oxygenation, and ventilation, is performed after cervical spinal immobilization (p. 64). 6. A 2-year-old has a suspected cervical spinal injury. In order to ensure neutral spinal alignment, padding should be placed under which area? a. Shoulders Rationale: The younger child has a larger head proportionally to the body and when lying supine is naturally in a position of cervical flexion. Padding under the shoulders or upper torso will bring the cervical spine into neutral alignment. The shoulder should be horizontally aligned with the external auditory meatus (p. 64). b. Head Rationale: Padding under the head will exacerbate this flexion (p. 64). c. Neck Rationale: Padding under the neck will not correct the anatomic flexion (p. 64). d. Waist Rationale: Padding under the waist will not affect the cervical spinal alignment (p. 64). A. Shoulders Rationale: The younger child has a larger head proportionally to the body and when lying supine is naturally in a position of cervical flexion. Padding under the shoulders or upper torso will bring the cervical spine into neutral alignment. The shoulder should be horizontally aligned with the external auditory meatus (p. 64). 7. The nurse is preparing to administer a feeding through a nasogastric feeding tube. The tube position was verified by radiograph after insertion 2 hours ago. What is the best way to verify placement before feeding? a. Instill air and listen over the epigastrium Rationale: The research regarding verification of gastric or feeding tube placement has demonstrated that the standard method of instillation of air and auscultation over the epigastrium for gurgling has been associated with improper placement and adverse outcomes (p. 103). b. Test the pH of the gastric contents Rationale: The research regarding verification of gastric or feeding tube placement has demonstrated that the standard method of instillation of air and auscultation over the epigastrium for gurgling has been associated with improper placement and adverse outcomes. The use of pH testing had been demonstrated to be safer and has been adopted as policy in many institutions (p. 103). c. Observe color of a gastric aspirate sample Rationale: Aspiration of gastric contents is done to perform pH testing, not observation of color (p. 103). d. Repeat the radiograph Rationale: Verification of placement by radiograph is generally done initially, but subsequent verifications are better established by pH testing (p. 103). B.) Test the pH of the gastric contents. Rationale: The research regarding verification of gastric or feeding tube placement has demonstrated that the standard method of instillation of air and auscultation over the epigastrium for gurgling has been associated with improper placement and adverse outcomes. The use of pH testing had been demonstrated to be safer and has been adopted as policy in many institutions (p. 103). 8. What is the best method to rapidly administer a 20 mL/kg bolus of 0.9% normal saline to a pediatric patient weighing 8 kg? a. A 20-mL syringe with a stopcock Rationale: With a 20-mL syringe and a three-way stopcock, the nurse can quickly deliver an appropriate bolus of 0.9% normal saline by drawing up and administering 20 mL once for each kilogram of the pediatric patient's weight or 8 times for this patient (p. 119). b. A syringe pump Rationale: A syringe pump is good for medication administration that needs to infuse over time, but it will take longer than the method using a 20-mL syringe and a stopcock (p. 119). c. A rapid infuser Rationale: Rapid infuser devices are used on patients weighing at least 25 kg and receiving a minimum of 500mL. This patient does not meet either requirement for use (p. 119). d. A pressure bag Rationale: A pressure bag is sometimes quite useful in administering a large amount of fluid; however, the higher pressures generated may result in venous rupture in younger children (p. 119). A.) A 20-mL syringe with a stopcock. Rationale: With a 20-mL syringe and a three-way stopcock, the nurse can quickly deliver an appropriate bolus of 0.9% normal saline by drawing up and administering 20 mL once for each kilogram of the pediatric patient's weight or 8 times for this patient (p. 119). 9. Immediately after intraosseous insertion the nurse assesses the infusion and notes that the fluid is not dripping. How should the nurse respond? a. Use an infusion pump to deliver the fluids Rationale: Fluids infusing through an intraosseous device do not necessarily run by gravity. The use of an infusion pump is usually required (p. 127). b. Remove the device and insert in another site Rationale: Fluids infusing through an intraosseous device do not necessarily run by gravity. This does not mean it is nonfunctional and removal is not indicated (p. 127). c. Advance the device and reassess the flow Rationale: Advancing the device if it is currently correctly placed may penetrate the far wall of the bone and produce infiltration (p. 127). d. Attempt to aspirate bone marrow Rationale: Aspiration of bone marrow confirms correct placement of an intraosseous device, but lack of return is not a sign of incorrect placement. Bone marrow aspiration is not always possible in some severely dehydrated pediatric patients (p. 127). A.) Use an infusion pump to deliver the fluids Rationale: Fluids infusing through an intraosseous device do not necessarily run by gravity. The use of an infusion pump is usually required (p. 127). 10. A 13-month-old presents to the emergency department with a 2-day history of a low-grade fever, increased work of breathing, and tonight developed a barking cough and inspiratory stridor. What condition does the nurse suspect? a. Epiglottitis Rationale: Epiglottitis has a sudden onset of high fever, sore throat, difficulty swallowing, and muffled voice and quickly progresses to drooling, tripod positioning, and stridor (p. 137). b. Foreign body aspiration Rationale: This patient is the right age for a foreign body aspiration as it is more common in infants and toddlers who explore the world orally, but the gradual onset, low-grade fever, and barking cough indicates an infectious process, specifically croup (p. 137). c. Tracheomalacia Rationale: Tracheomalacia is a chronic condition affecting the upper airway that may be an indication for a tracheostomy, but it is not acute, nor associated with infectious processes (pp. 136, 142-143). d. Croup Rationale: Croup is most commonly seen in children between the ages of 6 and 36 months and has a gradual onset of cold symptoms including a low-grade fever, tachypnea, tachycardia, retractions, and inspiratory stridor. The classic sign is a barking cough that worsens at night (p. 137). D.) Croup Rationale: Croup is most commonly seen in children between the ages of 6 and 36 months and has a gradual onset of cold symptoms including a low-grade fever, tachypnea, tachycardia, retractions, and inspiratory stridor. The classic sign is a barking cough that worsens at night (p. 137). 11. In providing education to a family regarding obtaining baseline peak airway flow for a child with asthma, the nurse will recommend what time of day? a. At bedtime. b. Before exercise c. In the morning. d. After meal. C.) In the morning. Rationale: The recommended time to obtain baseline peak flow readings is first thing in the morning before any administration of bronchodilator therapy (pp. 138, 140). 12. The nurse is planning to begin oral rehydration therapy for a 9-month-old with mild dehydration. She provides the caregivers with a glucose and sodium solution and instructs them to administer small amounts: a. Every 2 to 5 minutes Rationale: Oral rehydration should be attempted in those pediatric patients who can tolerate oral fluids with mild dehydration. Frequent (every 2 to 5 minutes), small sips of a commercially prepared glucose and sodium solution, such as Pedialyte or Infalyte, is the most successful method (p. 149). b. Every 10 to 12 minutes Rationale: Oral rehydration should be attempted in those pediatric patients who can tolerate oral fluids with mild dehydration. Frequent, small sips of a commercially prepared glucose and sodium solution, such as Pedialyte or Infalyte, is the most successful method (p. 149). c. Every 15 minutes Rationale: Oral rehydration should be attempted in those pediatric patients who can tolerate oral fluids with mild dehydration. Frequent, small sips of a commercially prepared glucose and sodium solution, such as Pedialyte or Infalyte, is the most successful method (p. 149). d. Every 30 minutes Rationale: Oral rehydration should be attempted in those pediatric patients who can tolerate oral fluids with mild dehydration. Frequent, small sips of a commercially prepared glucose and sodium solution, such as Pedialyte or Infalyte, is the most successful method (p. 149). A.) Every 2 to 5 minutes. Rationale: Oral rehydration should be attempted in those pediatric patients who can tolerate oral fluids with mild dehydration. Frequent (every 2 to 5 minutes), small sips of a commercially prepared glucose and sodium solution, such as Pedialyte or Infalyte, is the most successful method (p. 149). 13. Caregivers bring in their 3-week-old neonate and describe nonbilious vomiting after every feeding that is becoming more forceful over the past 24 hours. The last time he vomited the vomitus hit a chair 2 feet away. They say he cries, roots, and sucks vigorously on his pacifier right after vomiting as though still hungry. He is not experiencing any diarrhea. What condition is the most likely cause of these signs and symptoms? a. Intussusception Rationale: Intussusception occurs most commonly in males aged 3 to 12 months and manifests with episodic abdominal pain, drawing up of the legs, and vomiting. It is not associated with projectile vomiting (pp. 155-156) b. Volvulus Rationale: Volvulus presents with bilious vomiting, and not projectile (p. 156). c. Gastroenteritis Rationale: Gastroenteritis does present with vomiting but usually includes diarrhea and the vomiting is usually not projectile as seen in pyloric stenosis (p. 151). d. Pyloric stenosis Rationale: Pyloric stenosis is the narrowing of the pylorus, the opening from the stomach into the small intestine. It is most commonly seen in males between 2 and 8 weeks of age. They present with nonbilious vomiting, usually after every feeding, that becomes projectile as the obstruction worsens. With pyloric stenosis the infant remains constantly hungry and will demonstrate hunger behaviors after vomiting. If the diagnosis is delayed, dehydration and signs of hypovolemia may occur (p. 155). D.) Pyloric stenosis Rationale: Pyloric stenosis is the narrowing of the pylorus, the opening from the stomach into the small intestine. It is most commonly seen in males between 2 and 8 weeks of age. They present with nonbilious vomiting, usually after every feeding, that becomes projectile as the obstruction worsens. With pyloric stenosis the infant remains constantly hungry and will demonstrate hunger behaviors after vomiting. If the diagnosis is delayed, dehydration and signs of hypovolemia may occur (p. 155). 14. A neonate is delivered in the emergency department and placed on a radiant warmer. There is no staining of the amniotic fluid. What is the first step in neonatal resuscitation? a. Dry and warm the neonate Rationale: The steps in neonatal resuscitation are 1) dry and warm the patient, 2) maintain airway patency, 3) maintain breathing effectiveness, 4) maintain adequate circulation, 5) obtain vascular access, 6) administer medications, 7) intervene if positive pressure ventilation fails, and 8) volume expansion and vasopressor support. At each step, the neonate is assessed to determine response to care. If the response is absent or inadequate, the steps become more invasive and complex (pp. 187-189). b. Suction the mouth and nose Rationale: The steps in neonatal resuscitation are 1) dry and warm the patient, 2) maintain airway patency, which begins with positioning to open the airway, and suctioning the mouth first and then the nose with a bulb syringe, maintain breathing effectiveness, 4) maintain adequate circulation, 5) obtain vascular access, 6) administer medications, 7) intervene if positive pressure ventilation fails, and 8) volume expansion and vasopressor support. At each step, the neonate is assessed to determine response to care. If the response is absent or inadequate, the steps become more invasive and complex (pp. 187-189). c. Assess for effective breathing Rationale: The steps in neonatal resuscitation are 1) dry and warm the patient, 2) maintain airway patency, 3) maintain breathing effectiveness, which begins with gentle tactile stimulation, then blended oxygen, positive- pressure ventilation and intubation as needed, 4) maintain adequate circulation, 5) obtain vascular access, 6) administer medications, 7) intervene if positive pressure ventilation fails, and 8) volume expansion and vasopressor support. At each step, the neonate is assessed to determine response to care. If the response is absent or inadequate, the steps become more invasive and complex (pp. 187-189). d. Palpate a central pulse rate Rationale: The steps in neonatal resuscitation are 1) dry and warm the patient, 2) maintain airway patency, 3) maintain breathing effectiveness, 4) maintain adequate circulation, which begins with palpating a central pulse, either at the brachial artery or base of the umbilicus and cardiac compressions as needed, 5) obtain vascular access, 6) administer medications, 7) intervene if positive pressure ventilation fails, and 8) volume expansion and vasopressor support. At each step, the neonate is assessed to determine response to care. If the response is absent or inadequate, the steps become more invasive and complex (pp. 187-189). A.) Dry and warm the neonate. Rationale: The steps in neonatal resuscitation are 1) dry and warm the patient, 2) maintain airway patency, 3) maintain breathing effectiveness, 4) maintain adequate circulation, 5) obtain vascular access, 6) administer medications, 7) intervene if positive pressure ventilation fails, and 8) volume expansion and vasopressor support. At each step, the neonate is assessed to determine response to care. If the response is absent or inadequate, the steps become more invasive and complex (pp. 187-189). 15. In discussing the legal care of the adolescent patient, what is a mature minor? a. A minor who lives independently and is legally able to make health decisions Rationale: An emancipated minor is a minor who has been legally declared independent of his or her parent or guardian. Some examples are minors who are married, serve in the military, or are living independently from parents. These minors are considered an adult for healthcare decisions (p. 204). b. A minor who is able to make decisions regarding his or her own sexual or mental health Rationale: In most jurisdictions, adolescents are allowed to make decisions regarding specific health services, including reproductive health, pregnancy-related care, sexual health, drug and alcohol treatment, and mental health (pp. 204-205). c. A minor who is able to make decisions regarding healthcare as a parent of his or her own child Rationale: A minor who is a parent is generally considered an emancipated minor and is able to make decisions regarding his or her child's health (p. 204). d. A minor who lives with a parent or guardian but legally is able to make health decisions Rationale: A mature minor remains in the care and supervision of his or her parent or guardian but has been granted legal permission to make independent health care decisions. The adolescent must be able to understand the risks and benefits of possible treatments. This definition may vary by state or jurisdiction. Know your own local legal definitions (p. 204). D.) A minor who lives with a parent or guardian but legally is able to make health decisions. Rationale: A mature minor remains in the care and supervision of his or her parent or guardian but has been granted legal permission to make independent health care decisions. The adolescent must be able to understand the risks and benefits of possible treatments. This definition may vary by state or jurisdiction. Know your own local legal definitions (p. 204). 16. Which of the following screening statements/questions is most appropriate in assessing an adolescent for dating violence? a. "What triggers for violence have you experienced from your partner?" Rationale: Asking about triggers for violence may be interpreted as the victim doing something to cause the violence and he or she may wish to defend the relationship. This is especially true if the partner has isolated himself or herself from friends and family or if the victim already feels shame or guilt (pp. 214-215). b. "Does your partner feel entitled to sex even if you say 'no'?" Rationale: It may be difficult and unhelpful to ask the adolescent to answer from the perspective of the dating partner (p. 215). c. "Tell me about a time when you've felt unsafe in your relationship." Rationale: Dating violence in the adolescent population requires screening as intimate partner violence is screened in the adult population. Screening should include directive and probing questions to discover violence in a dating relationship. Asking the adolescent to relate a time he or she felt unsafe will help the nurse assess for violence without the accusations or judgment (p. 215). d. "Do you feel if you tried harder to please, your partner will not become violent?" Rationale: Victims of dating violence may feel that if they tried harder, their partners may be less violent, but this is a myth that should not be perpetuated (p. 215). C.) "Tell me about a time when you've felt unsafe in your relationship." Rationale: Dating violence in the adolescent population requires screening as intimate partner violence is screened in the adult population. Screening should include directive and probing questions to discover violence in a dating relationship. Asking the adolescent to relate a time he or she felt unsafe will help the nurse assess for violence without the accusations or judgment (p. 215). 17. Which sign distinguishes compensated shock from decompensated shock in the pediatric patient? a. Peripheral pulses Rationale: Compensatory mechanisms in the pediatric patient are systemic responses to the shock state to prevent hypotension and cardiovascular collapse. These mechanisms include peripheral vasoconstriction to shunt blood to vital organs, which manifests as weakening pulses, delayed capillary refill, and cool, mottled skin (pp. 231-232, 237). b. Blood pressure Rationale: Decompensated shock, also referred to as hypovolemic shock, occurs when the compensatory mechanisms in the pediatric patient, including increasing cardiac output with tachycardia and peripheral vasoconstriction to shunt blood to vital organs, which manifests as weakening pulses, delayed capillary refill, and cool, mottled skin. In pediatric patients, it is at this point that blood pressure drops and decompensated shock occurs (pp. 229, 231). c. Capillary refill Rationale: Compensatory mechanisms in the pediatric patient are systemic responses to the shock state to prevent hypotension and cardiovascular collapse. These mechanisms include peripheral vasoconstriction to shunt blood to vital organs, which manifests as weakening pulses, delayed capillary refill, and cool, mottled skin (pp. 229, 231). d. Level of consciousness Rationale: Changes in level of consciousness occur as cerebral perfusion drops. The signs include anxiety, irritability, restlessness, and lethargy, progressing to unresponsiveness and coma. As loss of consciousness develops, decompensation may be imminent, but the definition of decompensated shock is the onset of hypotension (pp. 229, 230). B.) Blood pressure Rationale: Decompensated shock, also referred to as hypovolemic shock, occurs when the compensatory mechanisms in the pediatric patient, including increasing cardiac output with tachycardia and peripheral vasoconstriction to shunt blood to vital organs, which manifests as weakening pulses, delayed capillary refill, and cool, mottled skin. In pediatric patients, it is at this point that blood pressure drops and decompensated shock occurs (pp. 229, 231). 18. A 5-year-old arrives to the emergency department unconscious with a heart rate of 32 beats/minute, weak, thready pulses, and pale, mottled skin. The team has begun bag-mask ventilation with 100% oxygen and chest compressions with no improvement in the heart rate. An intraosseous line is in place. Which of the following interventions is the priority? a. Administration of atropine Rationale: Atropine is only indicated in pediatric bradycardia if it is the result of vagal nerve stimulation. If the history does not indicate a reason for vagal stimulation, such as vigorous suctioning, the medication of choice is epinephrine (p. 251). b. Transcutaneous pacing Rationale: Transcutaneous pacing may be necessary if there is no response to epinephrine, but it should be given first (p. 251). c. Administration of epinephrine Rationale: For symptomatic bradycardia in the pediatric population, begin with oxygenation and ventilation. If those interventions do not raise the heart rate, the next step is epinephrine, which will increase peripheral vascular resistance and provide improved blood flow to vital organs and increase heart rate and contractility (pp. 250-251). d. Attempt vagal stimulation Rationale: Vagal stimulation is an intervention for supraventricular tachycardia, not bradycardia (p. 253). C.) Administration of epinephrine Rationale: For symptomatic bradycardia in the pediatric population, begin with oxygenation and ventilation. If those interventions do not raise the heart rate, the next step is epinephrine, which will increase peripheral vascular resistance and provide improved blood flow to vital organs and increase heart rate and contractility (pp. 250-251). 19. A 9-month-old infant pulled himself up onto the hearth of a fireplace. While doing so, he fell forward onto the hot glass doors and sustained deep partial thickness burns to the bilateral palmar aspects of both hands. What is the approximate percentage of total body surface area burned? a. 1% Rationale: An estimation of the burn area can be performed by assuming each palmar surface of the patient's hand represents approximately 1% of the total body surface area (p. 274). b. 2% Rationale: An estimation of the burn area can be performed by assuming each palmar surface of the patient's hand represents approximately 1% of the total body surface area. In this case, both hands equal 2% (p. 274). c. 4% Rationale: An estimation of the burn area can be performed by assuming each palmar surface of the patient's hand represents approximately 1% of the total body surface area (p. 274). d. 5% Rationale: An estimation of the burn area can be performed by assuming each palmar surface of the patient's hand represents approximately 1% of the total body surface area (p. 274). b. 2% Rationale: An estimation of the burn area can be performed by assuming each palmar surface of the patient's hand represents approximately 1% of the total body surface area. In this case, both hands equal 2% (p. 274). 20. An ambulance arrives with a 13-year-old pedestrian hit by a car. Identified injuries reported by paramedics include multiple abrasions to the head and face, a large, actively bleeding laceration to the forehead, hip pain with the leg externally rotated, and bruising across the chest and abdomen. The patient is in full spinal immobilization and has two intravenous catheters and a nonrebreather oxygen mask in place. Vital signs are BP 110/70 mm Hg, HR 118 beats/minute, RR 24 breaths/minute, and SpO2 96%. The Glasgow coma scale score is 15. What is the priority? a. Computed tomography Rationale: Although CT scans are an important diagnostic tool and are indicated for this patient for the cervical spine, chest, and abdomen, this test would not be performed until the primary and secondary surveys are completed and any primary or secondary issues are addressed (p. 270). b. Immobilize the femur Rationale: A femur fracture is concerning because of the potential for blood loss. However, the priority for this patient is controlling the obvious bleeding. Obvious external bleeding is controlled in the primary survey and femur immobilization is applied in the secondary survey (p. 283). c. A pressure dressing to the forehead Rationale: Control of active external bleeding is a high priority in order to minimize further hemodynamic instability during the circulation assessment in the primary survey. Younger children can lose relatively large amounts of blood from scalp lacerations (p. 13). d. Focused assessment with sonography for trauma (FAST) Rationale: Sonography may be useful given this patient's evidence of abdominal injuries, but the active bleeding from the forehead laceration is the priority (p. 282). C.) A pressure dressing to the forehead Rationale: Control of active external bleeding is a high priority in order to minimize further hemodynamic instability during the circulation assessment in the primary survey. Younger children can lose relatively large amounts of blood from scalp lacerations (p. 13). 21. A 15-year-old with a history of schizophrenia is taking risperidone (Risperdal) and lithium (Eskalith). She presents with dystonia, akinesia, a shuffling gait, muscle rigidity, and tremors. What does the nurse suspect is the cause of these signs and symptoms? a. Extrapyramidal symptoms Rationale: Extrapyramidal symptoms are an adverse effect caused by antipsychotic medications, including risperidone (Risperdal), aripiprazole (Abilify), quetiapine (Seroquel), olanzapine (Zyprexa), lithium (Eskalith), and valproate (Depakote). Extrapyramidal symptoms are characterized by akinesia, akathisia, dystonia, oculogyric crisis, pseudoparkinsonism or a shuffling gait, drooling, muscle rigidity, tremor, and rabbit syndrome (p. 324). b. Tardive dyskinesia Rationale: Tardive dyskinesia is an effect caused by antipsychotic medications, including risperidone (Risperdal), aripiprazole (Abilify), quetiapine (Seroquel), olanzapine (Zyprexa), lithium (Eskalith), and valproate (Depakote). Tardive dyskinesia presents with tongue protrusion, lip smacking, and involuntary movements of the mouth, fingers and extremities (p. 324). c. Neuroleptic malignant syndrome Rationale: Neuroleptic malignant syndrome is a potentially fatal syndrome caused by antipsychotic medications, including risperidone (Risperdal), aripiprazole (Abilify), quetiapine (Seroquel), olanzapine (Zyprexa), lithium (Eskalith), and valproate (Depakote) and can be precipitated by dehydration. Neuroleptic malignant syndrome presents with high fever, blood pressure instability, tachycardia, agitation, diaphoresis, pallor, muscle rigidity, and altered mental status (p. 324). d. Serotonin syndrome Rationale: Serotonin syndrome is the most serious adverse effect of selective serotonin reuptake inhibitors (SSRIs). Serotonin syndrome is characterized by altered mental status, flushing, diaphoresis, diarrhea, nausea, vomiting, myoclonus, tremors, hyperthermia, and tachycardia (pp. 323-324). A.) Extrapyramidal symptoms Rationale: Extrapyramidal symptoms are an adverse effect caused by antipsychotic medications, including risperidone (Risperdal), aripiprazole (Abilify), quetiapine (Seroquel), olanzapine (Zyprexa), lithium (Eskalith), and valproate (Depakote). Extrapyramidal symptoms are characterized by akinesia, akathisia, dystonia, oculogyric crisis, pseudoparkinsonism or a shuffling gait, drooling, muscle rigidity, tremor, and rabbit syndrome (p. 324).