BCEN CEN Practice Test

Contact precautions are the most appropriate initial measure for suspected multi-drug resistant organisms (MDROs) like MRSA or VRE. This involves wearing gloves and gowns when entering the patient's room and during patient care activities. While standard precautions are always necessary, they are not sufficient for suspected MDROs. Droplet precautions are typically used for respiratory infections, and airborne precautions are for pathogens that can remain suspended in the air, which is not the case for most MDROs causing skin infections. Implementing contact precautions helps prevent the spread of these resistant organisms to other patients and healthcare workers through direct contact or contact with contaminated surfaces.

The presence of hallucinations and delusional thinking, along with symptoms like high fever, elevated heart rate, and muscle rigidity, suggest a potential diagnosis of Neuroleptic Malignant Syndrome (NMS), especially if the patient has been on antipsychotic medication. Immediate discontinuation of any potential offending antipsychotic agent and symptomatic treatment is critical. While starting a new medication regimen might be necessary eventually, addressing possible NMS requires urgent medical attention to prevent further complications, such as renal failure or severe neurological damage. Although Hydrotherapy and adjustment of current antipsychotic medications are relevant considerations, they do not address the immediate life-threatening situation of NMS.

The correct answer is airway compromise requiring immediate intubation. The patient's presentation strongly suggests a Le Fort III fracture, which involves complete separation of the facial bones from the cranial base. This severe maxillofacial trauma can lead to rapid airway obstruction due to bleeding, edema, and mechanical displacement of structures.

While CT imaging is crucial for definitive diagnosis and surgical planning, it is not the primary concern in this scenario. The patient's respiratory distress indicates an impending airway emergency that requires immediate intervention.

Although controlling hemorrhage is important in maxillofacial trauma, the description doesn't indicate active severe bleeding that would take precedence over airway management.

While clear fluid dripping from the nose suggests a cerebrospinal fluid leak due to a dural tear, addressing this is not the most urgent concern when faced with potential airway compromise. Management of such leaks typically occurs after airway stabilization and complete trauma evaluation.

Heating systems, including furnaces, boilers, and water heaters, are common sources of carbon monoxide in homes. Inadequate ventilation or malfunction of these heating systems can lead to carbon monoxide build-up, which is odorless and colorless, making it a silent killer. Vehicles left running in enclosed spaces are also a significant source, but domestic heating systems are generally considered the primary culprits in accidental exposures in the home environment. Barbecues and portable heaters are typically used intermittently and are less likely to cause unintentional chronic exposures when used with proper precautions.

High altitude can lead to noncardiac pulmonary edema, known as High Altitude Pulmonary Edema (HAPE). The primary treatment for HAPE is descent to a lower altitude and supplemental oxygen. A beta-agonist bronchodilator is a treatment for conditions such as asthma or COPD, but it is not the primary intervention for HAPE.

Lower left quadrant abdominal pain is a typical symptom of diverticulitis, reflecting the common location of the inflamed diverticula in the sigmoid colon. In contrast, symptoms like severe right lower quadrant pain or generalized abdominal swelling are more indicative of conditions such as appendicitis or ascites respectively.

For suspected dislocations, immobilization is the priority to prevent further injury to the joint and surrounding structures. While analgesia is important, it is secondary to immobilization. Closed reduction is typically performed by a physician once the dislocation is confirmed by radiography and should not be attempted by nursing personnel prior to confirmation. Similarly, applying traction is part of the reduction process and should not be done without confirmation and medical direction.

The correct answer is bacterial infection. Osteomyelitis is primarily caused by bacterial infection of the bone. While trauma, surgery, or underlying medical conditions can increase the risk of developing osteomyelitis, they are not the primary cause. Bacteria, most commonly Staphylococcus aureus, enter the bone through various routes such as the bloodstream, direct inoculation, or spread from nearby soft tissue infections. Understanding the primary cause is crucial for emergency nurses to recognize risk factors, initiate appropriate diagnostic measures, and begin timely treatment to prevent complications.

The correct characterization of a Transient Ischemic Attack (TIA) is an episode of temporary neurological dysfunction resulting from focal ischemia, without leading to permanent infarction. TIA serves as a critical warning indicator for possible stroke, hence recognizing its traits helps in mitigating future severe outcomes. The description of a TIA specifically excludes permanent damage, which is a defining element of a stroke. Episodes of syncope involve temporary losses of consciousness caused frequently by vascular instability, not necessarily ischemic events, and vertigo is typically related to balance disturbances rather than ischemic neurological impairment.

Administering topical anesthetic drops is the most appropriate initial intervention for a suspected corneal abrasion. This helps alleviate pain and allows for a more thorough examination of the eye. However, it's important to note that these drops are for diagnostic purposes only and should not be prescribed for home use due to the risk of delayed healing and potential corneal damage.

Irrigation is not the first step, as it may cause further irritation to an already damaged cornea. While antibiotic ointment may eventually be prescribed, it's not the initial intervention. Patching the eye is generally not recommended for corneal abrasions, as it can increase the risk of infection and delay healing.

Pain out of proportion to the injury is the earliest and most reliable clinical sign of compartment syndrome. This severe pain often occurs before the development of other classic signs like paresthesia, pallor, or pulselessness. It's crucial for emergency nurses to recognize this early indicator, as compartment syndrome can lead to permanent tissue damage if not addressed promptly. While swelling and decreased range of motion are common in many injuries, they are not specific to compartment syndrome. Absent pulses are a late sign and indicate severe progression of the condition.

Neurogenic shock is characterized by hypotension with bradycardia. It occurs due to the loss of sympathetic tone and unopposed parasympathetic output after a spinal cord injury, leading to vasodilation and thus decreased cardiac output. Unlike other types of shock, the presence of bradycardia is distinctive because typically, shock presents with tachycardia where the body tries to compensate for low blood pressure by increasing the heart rate. Therefore, the presence of bradycardia in the setting of hypotension is a key indicator of neurogenic shock.

The correct answer is to obtain immediate surgical consultation. The patient's presentation of sudden severe abdominal pain, nausea, vomiting, and a rigid, board-like abdomen are classic signs of peritonitis, which is often caused by a perforated viscus. This is a surgical emergency that requires immediate evaluation by a surgeon for potential life-saving intervention.

While pain management and IV fluids are important supportive measures, they should not delay definitive treatment. CT scan can be helpful in diagnosis, but in this case, the clinical presentation strongly suggests peritonitis, and waiting for imaging could potentially delay necessary surgical intervention. Administering antibiotics is also important, but should not precede surgical consultation in this acute situation.

Remember, in cases of suspected peritonitis or perforated viscus, time is of the essence, and early surgical involvement is crucial for optimal patient outcomes.

The appropriate initial management for this patient, who shows signs of hyperkalemia, is administration of calcium gluconate. Calcium gluconate works by stabilizing the cardiac membrane against the effects of elevated serum potassium levels, which is essential to prevent further cardiac complications until more definitive hyperkalemia treatments can take effect. Insulin and dextrose, while used to treat hyperkalemia by driving potassium back into cells, are not the immediate treatment for cardiac protection. Sodium polystyrene sulfonate aids in the removal of excess potassium but acts slower and is not indicated for urgent symptom management.

The presentation of increasing pain, warmth, redness, and swelling around the wound site, combined with the patient's fever, are classic signs of a wound infection. These symptoms indicate that the body is responding to an infection likely caused by bacteria entering through the wound. The worsening of symptoms despite the passage of time since the injury further supports the diagnosis of an infection, not merely an inflammatory response to the injury itself.