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). - ANS ...
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). - ANS 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 - ANS 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.
C. the patient may be a victim of domestic violence.
D. the bruising is a result of the stated fall. - ANS 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. - ANS 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. - ANS 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. - ANS 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
A. repeat the neurologic assessment.
B. obtain orthostatic vital signs.
C. assess visual acuity.
D. obtain blood glucose measurement. - ANS 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. - ANS 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. - ANS 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 - ANS C. respiratory status.
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. - ANS 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 - ANS 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. - ANS 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. - ANS C. start chest compressions.
A patient presents with his family members, who state that he has struck his brother and has
been violent and paranoid. The nurse should FIRST
A. place the patient into a treatment room with the door open.
B. assess the brother for possible injuries.
C. escort the patient to the quiet room to await the social worker.
D. notify police of the assault. - ANS A. place the patient into a treatment room with the
door open.
Human tetanus immune globulin provides passive immunity for
A. 1 year.
B. 30 days.
C. 6 months.
D. 72 hours. - ANS B. 30 days.
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