Nokea
A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?
- A. Bulging anterior fontanel
- B. Repeated vomiting
- C. Signs of sleepiness at 10 PM
- D. Inability to read short words from a distance of 18 inches
Correct Answer: B
Rationale: Increased intracranial pressure after head trauma can lead to serious complications. Repeated vomiting is a concerning sign as it can indicate stimulation of the vomiting center within the brainstem due to increased pressure. This can be an early indicator of raised intracranial pressure and the need for urgent medical intervention. Bulging anterior fontanel may not be immediately apparent in a 4-year-old child and is more common in infants. Signs of sleepiness at a particular time of day are not specific to increased intracranial pressure. Inability to read short words from a distance of 18 inches may indicate vision problems but is not directly related to intracranial pressure.
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A client has no pulse or respirations. After calling for help, what should the nurse's first action be?
- A. Start a peripheral IV
- B. Initiate high-quality chest compressions
- C. Establish an airway
- D. Obtain the crash cart
Correct Answer: B
Rationale: In a situation where a client has no pulse or respirations, the initial action recommended by the American Heart Association is to start high-quality chest compressions. This action helps maintain blood flow to vital organs such as the brain until normal heart rhythm is restored. Starting CPR with chest compressions before checking the airway and providing rescue breaths is crucial to improve outcomes. While establishing an airway and obtaining a crash cart are important steps in resuscitation, initiating chest compressions takes precedence to ensure oxygenated blood circulation. Starting with chest compressions applies to adults, children, and infants but not newborns.
A patient underwent fiberoptic colonoscopy 18 hours ago and presents to the emergency department with increasing abdominal pain, fever, and chills. Which of the following conditions poses the most immediate concern?
- A. Bowel perforation
- B. Viral gastroenteritis
- C. Colon cancer
- D. Diverticulitis
Correct Answer: A
Rationale: The correct answer is bowel perforation. Bowel perforation is the most serious complication of fiberoptic colonoscopy, with signs such as progressive abdominal pain, fever, chills, and tachycardia indicating advancing peritonitis. Although colonoscopic perforation is rare (0.03% to 0.7% incidence), it can lead to high mortality and morbidity rates. Viral gastroenteritis (Choice B) typically presents with symptoms like diarrhea, nausea, vomiting, and abdominal cramps, but it is not the most immediate concern in this scenario. Colon cancer (Choice C) and diverticulitis (Choice D) are important conditions but are less likely to present acutely after colonoscopy compared to bowel perforation.
A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect?
- A. The patient will be admitted to the medicine unit for observation and medication.
- B. The patient will be admitted to the day surgery unit for sclerotherapy.
- C. The patient will be admitted to the surgical unit and resection will be scheduled.
- D. The patient will be discharged home to follow-up with his cardiologist in 24 hours.
Correct Answer: C
Rationale: A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture, which can be life-threatening. The standard treatment for a rapidly enlarging abdominal aortic aneurysm is surgical intervention to prevent rupture. Therefore, the appropriate action for the nurse to expect is that the patient will be admitted to the surgical unit, and resection will be scheduled. Observation and medication (Choice A) are not sufficient for a rapidly enlarging aneurysm, and sclerotherapy (Choice B) is not typically used for aortic aneurysms. Discharging the patient home (Choice D) would be inappropriate and dangerous given the risk of rupture.
A nurse caring for several patients in the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure?
- A. A patient admitted for myocardial infarction without cardiac muscle damage.
- B. A postoperative coronary bypass patient, recovering on schedule.
- C. A patient with a history of ventricular tachycardia and syncopal episodes.
- D. A patient with a history of atrial tachycardia and fatigue.
Correct Answer: C
Rationale: The correct answer is a patient with a history of ventricular tachycardia and syncopal episodes. An automatic internal cardioverter-defibrillator is used to deliver an electric shock to the heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. These patients are at high risk of life-threatening arrhythmias, which may result in syncope. Patients with atrial tachycardia and fatigue (Choice D) would not typically require an implantable cardioverter-defibrillator as their primary issue is related to atrial arrhythmias. Patients who have had a myocardial infarction without cardiac muscle damage (Choice A) or postoperative coronary bypass patients recovering on schedule (Choice B) are not necessarily at high risk for ventricular arrhythmias and would not be the primary candidates for an implantable cardioverter-defibrillator.
A 24-year-old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Based on the presenting signs and symptoms, which of the following would you most likely suspect?
- A. Diverticulosis
- B. Hypercalcemia
- C. Hypocalcemia
- D. Irritable bowel syndrome
Correct Answer: B
Rationale: The correct answer is Hypercalcemia. In this case, the patient's history of myeloma, constipation, intense abdominal pain, and polyuria suggests hypercalcemia. Elevated calcium levels can lead to polyuria, severe abdominal pain, and confusion. Diverticulosis (Choice A), characterized by small pouches in the colon wall, typically does not present with confusion and polyuria. Hypocalcemia (Choice C) is unlikely given the symptoms described. Irritable bowel syndrome (Choice D) does not typically cause confusion and polyuria as seen in hypercalcemia.