CEN - PRACTICE EXAM - SOLUTIONS. The nurse is caring for a patient wh...

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CEN - PRACTICE EXAM

ACTUAL EXAM WITH CORRECT

SOLUTIONS.

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

• myxedema crisis.
• Beck's triad.
• thyroid storm.
• hyperosmolar hyperglycemic nonketotic syndrome (HHNS). -

correct answer- C. Thyroid storm

Which of the following assessment findings associated with a skull fracture indicate the need for further intervention?

• otorrhea, nausea, and vomiting
• decreasing level of consciousness and restlessness
• early evidence of periorbital ecchymosis and photophobia
• rhinorrhea and headache or dizziness - correct 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 1 / 4

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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:

• the patient may have undiagnosed coagulopathy.
• the bruising was sustained during the motor vehicle crash.
• the patient may be a victim of domestic violence.
• the bruising is a result of the stated fall. - correct 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

• lactated Ringers.
• norepinephrine.
• normal saline.
• epinephrine. - correct 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

• epiglottitis.
• bronchiolitis. 2 / 4

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• croup.
• aspiration of a foreign body. - correct answer- A. epiglottitis

The nurse understands that adenosine is administered

• IV push over 1-2 seconds.
• as a bolus over 10-15 minutes.
• as a bolus over 1 hour.
• IV push over 1-2 minutes. - correct 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

• repeat the neurologic assessment.
• obtain orthostatic vital signs.
• assess visual acuity.
• obtain blood glucose measurement. - correct answer- A.

repeat the neurologic assessment.

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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

• initiation of targeted temperature management.
• initiation of stroke protocol.
• transport to the cardiac catheterization lab.
• transport to the neurovascular suite. - correct 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

• tell the patient to get himself under control.
• instruct the patient to be quiet and speak only when spoken

to.

• allow the patient to go home as soon as possible.
• encourage the patient to verbalize his feelings about the

situation. - correct 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

• pupillary response.
• peripheral pulses.
• respiratory status.
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