Status Epilepticus
A patient is actively seizing and has been unresponsive for 7 minutes. Which action should the nurse perform first?
A. Administer phenytoin IV push
B. Prepare the patient for EEG monitoring
C. Ensure airway patency and administer oxygen
D. Obtain a serum drug level
Correct Answer: C
Rationale: The initial priority in status epilepticus is maintaining the ABCs—airway, breathing, and circulation—before administering medications or diagnostic tests to prevent hypoxia and brain injury.
A patient’s ECG shows a rate of 50 bpm, narrow QRS complexes, and inverted P waves occurring just before each QRS. Which rhythm does this represent?
A. Sinus bradycardia
B. Accelerated junctional rhythm
C. Junctional rhythm
D. Junctional tachycardia
Correct Answer: C
Rationale: Junctional rhythm originates from the AV node, typically 40–60 bpm, with inverted or absent P waves and narrow QRS complexes.
A nurse caring for a patient with a history of childhood abuse provides care using trauma-informed principles. Which nursing statement best reflects this approach?
A. “I need to complete this procedure quickly, so please try to stay calm.”
B. “You’re safe here. I’ll explain each step before I touch you.”
C. “You don’t need to discuss the past unless it’s relevant to your care.”
D. “Let’s focus on moving forward rather than revisiting what happened.”
Correct Answer: B
Rationale: Trauma-informed care emphasizes safety, trust, transparency, empowerment, and avoiding re-traumatization. Explaining procedures and maintaining control supports patient autonomy and reduces anxiety.
A patient involved in a high-speed motor vehicle crash presents with no external wounds but exhibits hypotension, abdominal distention, and shoulder pain. What type of trauma should the nurse suspect?
A. Penetrating trauma
B. Blunt abdominal trauma
C. Open chest injury
D. Superficial soft tissue injury
Correct Answer: B
Rationale: Blunt trauma often causes internal injuries without external evidence, leading to concealed bleeding or organ rupture—common after acceleration-deceleration injuries like MVCs.
A patient arrives in the trauma bay after a physical assault and appears withdrawn and fearful during assessment. Which nursing intervention best reflects trauma-informed care?
A. Proceed quickly to complete the head-to-toe assessment.
B. Ask the patient to provide a detailed description of the assault immediately.
C. Explain each action before performing it and allow the patient choices when possible.
D. Reassure the patient that “you’re safe now, so there’s nothing to be afraid of.”
Correct Answer: C
Rationale: Trauma-informed care in acute settings focuses on safety, trust, and empowerment. Giving the patient control and explaining interventions prevents re-traumatization.
A patient with status epilepticus receives lorazepam but continues to seize. Which medication should the nurse anticipate administering next?
A. Midazolam
B. Phenytoin
C. Diazepam
D. Levetiracetam
Correct Answer: B
Rationale: If benzodiazepines fail to stop seizures, long-acting antiepileptics (phenytoin, valproate, or levetiracetam) are administered next to maintain seizure control and prevent recurrence.
The ECG shows a progressively lengthening PR interval until a QRS complex is dropped. What rhythm does this represent, and what is the initial treatment?
A. 2nd-degree Type II block; prepare for pacing
B. 2nd-degree Type I (Wenckebach); monitor and treat if symptomatic
C. 1st-degree block; no treatment needed
D. 3rd-degree block; immediate transcutaneous pacing
Correct Answer: B
Rationale: Mobitz Type I (Wenckebach) has a progressive PR prolongation until a QRS drops. Usually benign; treat only if symptomatic bradycardia occurs.
A veteran reports nightmares, flashbacks, and irritability that have persisted for two months following combat exposure. Which diagnosis is most appropriate?
A. Acute Stress Disorder
B. Adjustment Disorder
C. Post-Traumatic Stress Disorder (PTSD)
D. Panic Disorder
Correct Answer: C
Rationale: PTSD symptoms persist for more than one month following trauma and include re-experiencing, avoidance, and hyperarousal features. Acute stress disorder lasts ≤1 month.
A construction worker was struck by falling debris and is unresponsive with gurgling respirations. What is the nurse’s first priority according to the primary survey?
A. Obtain a full set of vital signs
B. Insert two large-bore IVs
C. Clear and maintain the airway while stabilizing the cervical spine
D. Expose the patient to identify additional injuries
Correct Answer: C
Rationale: In trauma care, A = Airway with cervical spine protection is the first priority. Airway management must occur before breathing and circulation interventions.
A young adult fell from a two-story roof and has normal external appearance but complains of abdominal pain and shoulder discomfort. The nurse recognizes this as a potential sign of:
A. Rib fracture with pulmonary contusion
B. Internal hemorrhage from blunt abdominal trauma
C. Cervical spine injury
D. Stress-related somatic pain
Correct Answer: B
Rationale: Referred shoulder pain (Kehr’s sign) after blunt trauma suggests splenic or intra-abdominal bleeding, requiring rapid imaging and stabilization.
A patient with a traumatic brain injury has a GCS that dropped from 13 to 8 over 30 minutes, with unequal pupils and irregular respirations. What is the nurse’s immediate action?
A. Elevate the head of the bed to 90°
B. Notify the provider and prepare for emergent intervention
C. Reassess the GCS in one hour
D. Administer an analgesic for comfort
Correct Answer: B
Rationale: Rapid decline in GCS and abnormal pupils indicate increased ICP or impending herniation—a neurological emergency requiring immediate provider notification and airway stabilization.
A patient’s ECG shows a polymorphic ventricular tachycardia with a “twisting” QRS pattern. The patient is pulseless. What is the priority nursing action?
A. Administer amiodarone IV
B. Defibrillate immediately and give IV magnesium
C. Start transcutaneous pacing
D. Prepare for synchronized cardioversion
Correct Answer: B
Rationale: Torsades de Pointes is a lethal rhythm that requires defibrillation if pulseless and IV magnesium sulfate to correct the underlying QT prolongation and hypomagnesemia.
A college student is struggling academically and socially after moving away from home three months ago. The nurse suspects an adjustment disorder. Which intervention is most therapeutic?
A. “You should try to stop worrying and just focus on school.”
B. Encourage counseling and development of healthy coping strategies.
C. Suggest using alcohol to help relax during stressful periods.
D. Recommend isolation to limit emotional triggers.
Correct Answer: B
Rationale: Adjustment disorders respond well to supportive therapy, reassurance, and building adaptive coping strategies such as counseling, journaling, or exercise.
Which nursing intervention is most appropriate for a patient with a penetrating chest wound from a knife?
A. Remove the knife immediately to control bleeding
B. Apply firm pressure directly to the wound
C. Stabilize the knife in place and secure with bulky dressing
D. Perform vigorous suctioning to clear the airway
Correct Answer: C
Rationale: Never remove impaled objects—they may be tamponading major vessels. Stabilize in place, control bleeding around the site, and prepare for surgical management.
A patient involved in a fatal motor vehicle collision reports nightmares and intense guilt two weeks later. Which diagnosis and nursing action are most appropriate?
A. PTSD; initiate exposure therapy
B. Adjustment disorder; focus on coping and reassurance
C. Acute stress disorder; provide grounding techniques and emotional support
D. Depression; initiate antidepressant therapy
Correct Answer: C
Rationale: Acute stress disorder develops within one month of trauma. Early support, grounding, and reassurance can prevent progression to PTSD.
After a generalized tonic–clonic seizure, the patient is drowsy and confused. Which assessment finding would require immediate intervention?
A. Disorientation to place and time
B. Systolic BP 150 mmHg and HR 95 bpm
C. Gurgling respirations and drooling
D. Mild tremors of the hands
Correct Answer: C
Rationale: Airway obstruction is the greatest post-seizure risk. Gurgling and drooling indicate retained secretions and impaired protective reflexes—suction and airway maintenance are the priority.
A patient with a permanent pacemaker has ECG spikes visible, but some are not followed by QRS complexes. The nurse recognizes this as:
A. Failure to capture
B. Failure to fire
C. Failure to sense
D. Loss of pacing threshold
Correct Answer: A
Rationale: Failure to capture occurs when a pacemaker spike doesn’t produce myocardial depolarization (no QRS after spike). Causes include lead displacement or battery malfunction.
During assessment, a patient discloses ongoing intimate partner violence but says, “Please don’t tell anyone. I don’t want to get him in trouble.” What is the nurse’s priority action?
A. Respect the patient’s wishes and provide emotional support.
B. Document objectively and notify appropriate authorities.
C. Ask the partner for their perspective on the situation.
D. Provide discharge instructions and follow-up referrals.
Correct Answer: B
Rationale: Nurses are mandatory reporters for suspected or confirmed abuse of vulnerable individuals. The nurse must document objective findings and report immediately while ensuring patient safety.
A trauma patient arrives at the ED within minutes of a rollover crash. Why is rapid intervention during the first hour post-injury so critical?
A. It prevents psychological trauma associated with injury.
B. It minimizes risk of infection from open wounds.
C. It decreases mortality by restoring oxygenation and perfusion early.
D. It ensures diagnostic imaging can be completed before decompensation.
Correct Answer: C
Rationale: The “Golden Hour” focuses on rapid stabilization and restoration of airway, breathing, and circulation to prevent irreversible shock and multi-organ failure.
A nurse caring for a domestic violence survivor with multiple contusions notices that the patient becomes tearful when the partner enters the room. What is the nurse’s priority action?
A. Document the emotional reaction and continue the assessment.
B. Reassure the patient that the partner can help with recovery.
C. Ask the partner to step out to speak privately with the patient.
D. Contact social services after discharge.
Correct Answer: C
Rationale: Ensuring immediate safety and privacy is the first priority. Speaking privately allows accurate assessment and supports mandatory reporting if abuse is suspected.
A patient with a severe TBI and ICP of 25 mmHg begins having continuous seizure activity. Why is this finding especially concerning?
A. Seizures increase ICP and cerebral metabolic demand
B. Seizures reduce cerebral oxygen use
C. Seizures improve autoregulation of blood flow
D. Seizures indicate brainstem recovery
Correct Answer: A
Rationale: Seizures significantly raise intracranial pressure and oxygen consumption, worsening cerebral edema and ischemia. Immediate seizure control is essential to prevent secondary brain injury.
Which statement made by a patient with a new permanent pacemaker indicates the need for further teaching?
A. “I’ll avoid putting my phone in the shirt pocket over the pacemaker.”
B. “I can stand near a running microwave oven at home.”
C. “I should not walk through airport security scanners.”
D. “I’ll keep my pacemaker ID card with me at all times.”
Correct Answer: C
Rationale: Patients can safely pass through airport scanners but should avoid lingering near them. They must carry an ID card and avoid strong magnets or close proximity to powerful electrical equipment.
A survivor of childhood sexual abuse expresses guilt and shame during therapy. Which nursing response best promotes recovery?
A. “You shouldn’t feel guilty; it wasn’t that bad.”
B. “You were a child and not responsible for what happened to you.”
C. “Try not to think about the past—it will only make you upset.”
D. “You should confront the person who hurt you to find closure.”
Correct Answer: B
Rationale: Survivors often internalize guilt and shame. Validating the patient’s lack of blame and reinforcing safety and control fosters empowerment and emotional healing.
During the secondary survey of a trauma patient, the nurse notes absent breath sounds on the right and tracheal deviation to the left. What intervention should the nurse anticipate immediately?
A. Administer IV fluids and oxygen
B. Prepare for emergent needle decompression
C. Apply an occlusive dressing over the right chest
D. Elevate the head of the bed and continue assessment
Correct Answer: B
Rationale: These findings indicate tension pneumothorax, a life-threatening emergency requiring immediate needle decompression to relieve intrathoracic pressure and restore ventilation.
During the “golden hour,” trauma nurses focus on airway, breathing, and circulation. In the weeks after discharge, the same patient exhibits flashbacks and emotional numbing. What is the most appropriate nursing action?
A. Encourage the patient to avoid discussing the trauma.
B. Refer the patient for mental health evaluation for possible PTSD.
C. Reassure the patient that these symptoms are normal and temporary.
D. Focus follow-up solely on physical wound healing.
Correct Answer: B
Rationale: After the acute phase, survivors of major trauma are at risk for post-traumatic stress. Early referral for counseling or therapy promotes holistic recovery and prevents chronic psychological complications.