BCEN CEN Practice Test

Intramuscular epinephrine is the first-line treatment for anaphylaxis as it quickly works to reverse the pathophysiologic processes of anaphylaxis, which can include airway edema, hypotension, and shock. Antihistamines, while useful for symptomatic relief of urticaria and pruritus, do not address the hemodynamic and respiratory issues as effectively. Corticosteroids have a delayed onset and are not the primary treatment in the acute management of anaphylaxis. Normal saline is supportive treatment for hypotension but does not counteract the underlying anaphylactic reaction.

The correct answer is 'A specific plan for suicide with access to lethal means.' This is the most concerning finding because it indicates that the patient has not only thought about suicide but has also formulated a concrete plan and has the means to carry it out. This combination significantly increases the immediacy of the suicide risk.

While 'A history of previous suicide attempts' is a significant risk factor, it doesn't necessarily indicate imminent risk. Similarly, 'Expressing feelings of hopelessness' is a warning sign but doesn't imply immediate danger. 'Recent loss of a loved one' is a potential trigger for suicidal thoughts, but alone it doesn't indicate a high level of imminent risk.

As an emergency nurse, recognizing the severity of a specific plan combined with access to means is crucial for immediate intervention and potentially life-saving actions.

The appropriate initial step for a patient presenting with symptoms suggestive of C. difficile infection is to initiate contact precautions and collect a stool sample for testing. This prevents the spread of the bacteria and confirms the diagnosis, allowing for specific treatment. Administering further antibiotics without testing may worsen the condition if wrongly selected, hydrating the patient while necessary, doesn’t address the underlying cause directly at this point, and monitoring vital signs, while important, is not specific enough as an initial intervention for suspected C. difficile.

Sudden onset of multiple floaters and photopsia followed by a curtain or shadow moving over part of the visual field is classic for a rhegmatogenous retinal detachment. Liquefied vitreous passes through a retinal tear, separating the neurosensory retina from the pigment epithelium. This is an ocular emergency that requires immediate ophthalmologic evaluation to prevent permanent vision loss.

Distractors:

• Acute angle-closure glaucoma produces severe eye pain, headache, nausea, and halos around lights due to a rapid rise in intraocular pressure, not a curtain-like field defect.
• Age-related macular degeneration leads to gradual, painless loss of central vision and distortion (metamorphopsia), not an abrupt peripheral shadow.
• Bacterial conjunctivitis presents with conjunctival injection and purulent discharge but does not cause floaters, flashes, or visual-field loss.

The third heart sound (S3) occurs in early diastole when a large volume of blood enters a dilated, compliant ventricle. Although its sensitivity is low (detected in a minority of patients), its presence is one of the most specific bedside indicators of acute heart failure, far exceeding the specificity of crackles, peripheral edema, or jugular venous distension. The other findings listed are either less specific or signify different pathologies.

Healthcare guidelines advise that competent adult patients should be asked for permission before involving law enforcement, unless the situation meets mandatory reporting criteria (e.g., minor, vulnerable adult, or imminent danger). This respects patient autonomy, builds trust, and reduces the risk of retaliation by traffickers. Immediate notification without consent (Option A) can endanger the patient; simply discharging without offering help (Option C) neglects duty of care; detaining the patient until police arrive (Option D) violates legal and ethical standards.

Alkali substances cause liquefactive necrosis because they saponify fats, leading to deep penetrating injuries that can continue to cause tissue damage even after the initial exposure. Acids typically cause a coagulative necrosis, forming a protective eschar that limits the depth of tissue injury.

Cardiogenic pulmonary edema is the hallmark serious complication of scorpion envenomation. Venom-induced massive catecholamine release and direct myocardial toxicity can precipitate acute left-ventricular failure, leading to pulmonary edema and, in some cases, shock. Pulmonary edema and cardiogenic shock are repeatedly cited as the leading causes of death in both adult and pediatric sting victims. Anaphylaxis, while possible (usually after prior sensitization or during antivenom infusion), is documented only rarely. Acute hepatic failure and disseminated intravascular coagulation have been reported in isolated cases but are not typical or common outcomes.

After establishing an effective airway and adequate ventilation, and confirming a stable heart rate of over 100 bpm along with improved skin coloration, the appropriate next step is to monitor the baby and maintain temperature control. This step is vital as newborns are prone to hypothermia, which can complicate recovery. Immediate, aggressive interventions like administering intravenous fluids or supplemental oxygen might not be necessary with the stabilization of vital parameters and can in fact complicate the clinical scenario if not indicated.

The most appropriate next step in managing this patient's condition is an immediate surgical consultation for fasciotomy. This patient is showing signs of acute compartment syndrome, which is characterized by increased pressure within a muscle compartment that can impair circulation and cause muscle and nerve damage. Immediate intervention is critical to release the pressure and prevent permanent damage. Measuring compartment pressures might support the diagnosis but does not address the urgency of surgical intervention. Administering additional analgesia might help in managing pain but does not treat the underlying compartment syndrome. Reassessment in several hours could lead to worsening of the condition and is inappropriate given the current signs and symptoms.

Administering intravenous antibiotics is the priority intervention for a patient with advancing cellulitis from a wound infection. Cellulitis is a spreading bacterial infection of the skin and underlying tissues that can progress rapidly and lead to serious complications if not treated promptly. IV antibiotics provide rapid systemic distribution of the medication, which is crucial for controlling the spreading infection.

While the other options are important aspects of wound care:

• Elevating the affected limb helps reduce swelling but doesn't directly combat the infection.
• Applying warm compresses may increase blood flow to the area but doesn't address the underlying bacterial cause.
• Debriding the wound might be necessary in some cases, but it's not the first priority for advancing cellulitis and could potentially spread the infection further if done before antibiotic treatment.

The key in managing advancing cellulitis is to quickly initiate systemic antibiotic therapy to prevent further spread of the infection and potential complications such as sepsis or necrotizing fasciitis.

The correct term is 'intentional overdose,' which specifically refers to taking a substance, such as medication or illegal drugs, with the purpose of harming oneself. This distinguishes it from accidental ingestions, which are not intentional acts. Other terms may refer to different scenarios, such as 'substance use,' which does not imply self-harm, or 'overconsumption,' which can occur without harmful intent. Recognizing the distinction is vital for understanding patient motivations and providing appropriate care.

The correct answer is MDMA (Ecstasy) toxicity. MDMA is a common party drug that can cause a constellation of symptoms including confusion, agitation, and hyperthermia. This condition, known as serotonin syndrome, is a potentially life-threatening reaction to excessive serotonergic activity in the central nervous system.

Alcohol intoxication typically causes depressant effects and would not explain the hyperthermia. Opioid overdose usually presents with respiratory depression and pinpoint pupils, not agitation and hyperthermia. While cocaine can cause agitation and hyperthermia, it's less commonly associated with confusion and is not typically taken in pill form at music festivals.

In managing MDMA toxicity, the priority is to address hyperthermia through cooling measures and to provide supportive care. Benzodiazepines may be used to manage agitation. It's crucial for emergency nurses to recognize the signs of various substance-related emergencies to provide appropriate and timely care.

The correct answer is to apply a protective shield over the eye without applying pressure. In cases of penetrating eye injuries, it's crucial to protect the eye from further damage while avoiding any pressure that could exacerbate the injury. A protective shield (such as a paper cup) should be placed over the eye to prevent accidental movement of the foreign body.

Administering pain medication, while important, is not the immediate priority. Removing the nail is absolutely contraindicated as it could cause severe damage and vision loss. Bandaging both eyes, while sometimes done for eye injuries to prevent sympathetic movement, is not the first step and could be disorienting for the patient in this scenario.

The primary goal is to stabilize the injury, prevent further damage, and prepare the patient for emergency ophthalmological evaluation and possible surgical intervention. After shielding the eye, other steps would include obtaining a detailed history, assessing visual acuity in the unaffected eye, and arranging for immediate ophthalmology consultation.

A degloving injury occurs when an extensive section of skin and subcutaneous tissue is separated from the underlying muscle, fascia, or bone. This type of injury is often seen in high-energy trauma, such as motor vehicle accidents or industrial incidents. It's important to differentiate degloving injuries from other types of wounds because they require specialized management due to the extensive tissue damage and potential for complications like infection and tissue necrosis. Unlike simple lacerations or abrasions, degloving injuries involve a large area of tissue separation and often require complex surgical interventions for proper treatment.

The correct answer is to avoid inducing emesis and dilute with water or milk. This is the best initial management strategy for alkali ingestion because:

1. Inducing emesis is contraindicated in alkali ingestions as it can cause re-exposure of the esophagus to the corrosive substance, potentially worsening the injury.

2. Dilution with water or milk helps to reduce the concentration of the alkali and minimize further tissue damage. This should be done immediately if the patient is alert and able to swallow.

3. Neutralization with weak acids is not recommended as it can cause an exothermic reaction, potentially increasing tissue damage.

4. Gastric lavage is generally contraindicated in corrosive ingestions due to the risk of perforation and aspiration.

It's important to note that while dilution is the best initial step, the patient will require further assessment and management, including possible endoscopy and supportive care.

The correct answer is Diabetic Ketoacidosis (DKA). This patient presents with classic symptoms of DKA: nausea, vomiting, and abdominal pain. The high blood glucose (485 mg/dL) and low arterial pH (7.21) are hallmark signs of DKA. In DKA, the body cannot use glucose for energy due to insulin deficiency, leading to the breakdown of fats and the production of ketones, which causes metabolic acidosis.

Hyperosmolar Hyperglycemic State (HHS) typically has even higher glucose levels (often >600 mg/dL) and less severe acidosis. Hypoglycemia would present with a low blood glucose, not high. Lactic acidosis, while it can cause a low pH, doesn't typically present with such high glucose levels and is more commonly associated with severe illness, shock, or certain medications.

The primary cause of esophageal varices is portal hypertension, which is an increased pressure within the portal vein system. This condition is most often a complication of cirrhosis of the liver, where scar tissue obstructs blood flow. The increased pressure forces blood to be rerouted through smaller, collateral veins, such as those in the esophagus, causing them to dilate and form varices. Mallory-Weiss syndrome involves a tear in the esophageal lining, peptic ulcer disease is caused by erosion of the lining, and gastritis is inflammation of the stomach lining; none of these are the direct cause of variceal formation.

The presentation is suggestive of acute decompensated heart failure with pulmonary edema. The administration of intravenous diuretics, such as furosemide, is a key initial treatment in managing fluid overload and reducing pulmonary congestion in this situation. Nitroglycerin may also be used to reduce preload and afterload but is not the initial medication of choice. Oxygen therapy alone will not address the fluid overload and is an adjunct treatment. Intravenous morphine is not the primary treatment for heart failure and is used cautiously, mainly for palliative care to ease dyspnea and anxiety in end-stage heart failure, not as an initial line of treatment.

In patients with acute coronary syndrome (ACS), particularly older adults and those with diabetes, presentations can be atypical. While nausea, diaphoresis, and epigastric discomfort are all potential symptoms of ACS, they are non-specific. An epigastric burning sensation is easily confused with gastroesophageal reflux disease (GERD). However, pain that radiates to the jaw or left arm is a classic and more specific indicator of cardiac ischemia. This finding should significantly raise the suspicion for ACS, even when other symptoms seem vague or attributable to other conditions.