I've Fallen and I Can't Get Up
A 75-year old patient arrives in the emergency department by ambulance after a trip and fall down 4 steps. Which of the following assessment findings is consistent with a posterior hip dislocation?
A. Leg shortening and external rotation
B. Pain in groin and knee
C. Joint feels locked, and patient cannot move leg
D. Hip flexed, adducted, and internally rotated
What is D
Hip flexion, adduction, and internal rotation are consistent with posterior dislocation, whereas anterior dislocation is associated with flexion, abduction, and external rotation. Leg shortening and external rotation are associated with extracapsular trochanteric fractures of the hip (A). Pain in the groin, hip, or knee is associated with hip fractures. Either type of hip dislocation will cause the joint to feel locked (C).
You have an order to irrigate the ear of an adult patient to remove cerumen. There are no contraindications to irrigation in this patient. Which is an appropriate step in the procedure?
A. Pull the ear down and outward
B. Irrigate using room-temperature solution
C. Direct the solution toward the posterior wall of the ear canal
D. Occlude the opening of the ear canal with the irrigation syringe
What is C
When performing ear irrigation, the irrigating solution should be directed toward the upper back of the ear canal, which will bounce the solution off the upper canal and send it behind the cerumen. The ear should be pulled up and outward in the adult, and it should be pulled posteriorly and inferiorly in a small child (A). The irrigating solution should be at body temperature to decrease the chance of dizziness and a caloric response (B). Place the tip of the syringe at the opening of the ear canal, but do not occlude the canal, because excessive pressure from irrigation could damage the tympanic membrane.
A patient is brought to the emergency department from the local correctional facility, exhibiting signs of alcohol withdrawal. The patient reports his last drink was 12 hours ago. Which of the following would not be an expected assessment finding in the first 12 hours?
A. Hand tremors
B. Diaphoresis
C. Seizures
D. Delirium
What is D
Delirium tremens, which occurs in about 5% of alcohol withdrawal patients, appears between 48 and 96 hours into withdrawal. Tremulousness and diaphoresis occur in the first 6 to 36 hours (A, B). Seizures typically appear 6 to 48 hours into withdrawal (C).
An ambulatory patient with a history of chronic alcohol use presents to the emergency department with a report of acute onset of constant mid epigastric pain that radiates to the back. The pain started after he ate his dinner. Which of the following initial laboratory values, specific to these symptoms, would the nurse expect to be elevated?
A. Calcium
B. Amylase
C. Lactate
D. Albumin
What is B
This patient is presenting with classic symptoms of acute pancreatitis. The symptoms of acute pancreatitis frequently occur after a large meal or excessive alcohol use. Symptom onset is often abrupt, with patients reporting severe mid-epigastric pain radiating to the back. When pancreatic cells are damaged, amylase and lipase levels are significantly elevated. Calcium, lactate, and albumin levels are not specific to pancreatitis. However, in cases of severe pancreatitis, the patient may experience hypocalcemia because necrotic enzyme action uses up calcium.
The best indication of adequate tissue perfusion in a patient in shock is
A. a urine output of 30 mL/h.
B. an oxygen saturation of greater than 70%.
C. a central venous pressure of 10 cm H2O.
D. a capillary refill time of greater than 2 seconds.
What is A
Urine output is the best indicator of adequate tissue perfusion. It is desirable to have an oxygen saturation of much greater than 70% and a capillary refill time of LESS than 2 seconds.
A 75-year-old alert and oriented ambulatory patient is brought to the emergency department after tripping over his dog and falling. Which of the following complaints at triage has the highest priority?
A. Pain in the right wrist
B. Hematoma on the forehead
C. Weakness in both upper extremities
D. Left hip pain
What is C
Weakness in both upper extremities after a fall is a possible sign of an incomplete spinal cord injury. Patients with injuries to the central part of the spinal cord may have paralysis or loss of control of hand and arm movements. Pain in the wrist (A) and hip (D) would require further investigation, as well as the hematoma (B), but these would be evaluated after the potential spinal cord injury was addressed.
In an African American patient presenting to the emergency department with lip swelling, which information from the history would indicate a need for assignment to a higher patient acuity?
A. The patient is using a new lip balm
B. The patient was struck in the face by an object yesterday
C. The patient was stung by a wasp 48 hours ago
D. The patient is taking an angiotensin-converting (ACE) inhibitor
What is D
ACE inhibitors place the patient at increased risk for angioedema. Although this condition is more common early in therapy, angioedema can develop years after patients start therapy. The condition is more common in African Americans, women, Asians, and smokers. Patients who present to the emergency department and are taking ACE inhibitors need to be triaged as high-acuity patients because they can progress rapidly to airway compromise. Although options A, B, and C can cause lip swelling, they are less likely to progress to airway compromise.
A young adult spilled e-liquid on his clothing and skin while filling an e-cigarette. The patient presents to the emergency department with signs of mild nicotine toxicity. The nurse would expect to see which sign or symptom in this patient?
A. Excessive salivation
B. Hypotension
C. Bradycardia
D. Muscle weakness
What is A
Nicotine stimulates nicotinic receptors resulting in cholinergic excess. Symptoms include vomiting, abdominal pain, hypertension, tachycardia, tremors, and excessive salivation. Very high concentrations of nicotine can lead to seizures and respiratory failure. Nicotine is easily absorbed through all routes, including the skin, inhalation, gastrointestinal system, and mucous membranes. The e-liquid can easily spill or be extracted from e-cigarettes, which can also put children and consumers at risk.
A pregnant woman visiting a family member in the emergency department experiences spontaneous rupture of membranes and prolapse of the umbilical cord. Which intervention would be the highest priority?
A. Elevate the hips
B. Provide oxygen via mask at 8 to 10 L/min
C. Obtain peripheral venous access
D. Initiate fetal monitoring
What is A
Care of the patient with cord prolapse will require immediate interventions to prevent cord compression and interprofessional collaboration to ensure a positive outcome. The highest priority intervention is elevating the hips by placing the patient in the Trendelenburg, a modified Sims, or the knee-chest position to reduce pressure on the cord. A gloved hand can also be used to elevate the presenting part off the cord. Oxygen should be administered to help prevent fetal hypoxia. Fetal monitoring should be initiated, and peripheral venous access and blood specimens should be obtained.
According to the American Heart Association 2015 guidelines, which intervention is recommended when providing care for an adult patient in cardiac arrest who has ventricular fibrillation?
A. Shocking with a monophasic defibrillator at 200 joules
B. Administering 1 mg of epinephrine
C. Administering a single dose of vasopressin
D. Administering a lidocaine infusion
What is B
The American Heart Association 2015 guidelines recommend use of 1 mg of epinephrine administered either intravenously or intraosseously after the second defibrillation. Use of high- dose epinephrine is no longer recommended. The recommended energy dose for a monophasic defibrillator is 360 joules, whereas the recommended energy dose for a biphasic defibrillator is 120 to 200 joules. Administration of a single dose of vasopressin is no longer recommended in the adult cardiac arrest algorithm. The routine use of a lidocaine infusion after return of spontaneous circulation is not supported by the evidence.
An 82-year-old patient sustained a fractured hip in a recent fall. In evaluating the patient's condition, the nurse should be especially concerned about the
A. cause of the fall.
B. time the fall occurred.
C. degree that the affected leg is rotated outward.
D. patient's history of drug allergies.
What is A
Elderly patients are at risk for falls. The etiology of the fall is investigated to rule out a cardiac, vascular, or neurologic origin. The other options are components of the nursing history and assessment. The most important assessment at this time is to determine the etiology of the fall.
A patient is being discharged from the emergency department with a prescription for ciprofloxacin extended-release tablets. Which of the following should the nurse include in discharge teaching for this patient?
A. “Take this drug with food or a glass of milk to avoid stomach upset.”
B. “If you have trouble swallowing, you can always crush the pills.”
C. “Avoid caffeine because it will reduce the effectiveness of the drug.”
D. “If you develop tingling or pins and needles in your hands and feet, stop taking the drug, and contact your health care provider.”
What is D
Fluoroquinolones, in addition to tendonitis and tendon rupture, have been associated with peripheral neuropathy that can have rapid onset and become permanent. Milk and calcium-fortified products (A) can reduce absorption of ciprofloxacin and should not be taken at the same time. Extended-release tablets (B) should not be crushed. Ciprofloxacin may cause caffeine (C) to accumulate in the body, resulting in an increased caffeine effect, but it does not reduce the effectiveness of the drug.
A patient is being treated for ingestion of a synthetic cannabinoid. An electrocardiogram reveals that the patient has a prolonged QTc interval. Which laboratory result would be most concerning in this patient?
A. Potassium, 5.3 mEq/L
B. Calcium, 9.5 mg/dL
C. Magnesium, 1.4 mEq/L
D. Phosphorus, 2.0 mEq/L
What is C
Synthetic cannabinoid poisoning can cause a drug-induced delay in ventricular repolarization (prolonged QTc interval), increasing the risk of cardiac arrhythmias, such as torsades de pointes. Both hypokalemia and hypomagnesemia can contribute to the development of cardiac arrhythmias. Drugs that may delay ventricular repolarization should be avoided, and serial serum electrolytes should be monitored carefully. In this situation, the potassium level is at the upper level of normal, but the magnesium level is low (normal, 1.5-2.5 mEq/L).
Which of the following findings suggests that a patient may have a ruptured ovarian cyst?
A. intermittent abdominal pain
B. sharp abdominal pain
C. bloody vaginal discharge
D. thick yellow vaginal discharge
What is B
The pain associated with a ruptured ovarian cyst is characterized as sharp and constant rather than intermittent. There is usually no associated vaginal discharge.
You are caring for a patient undergoing therapeutic hypothermia while waiting for an intensive care unit bed. Which of the following would be an expected outcome of therapeutic hypothermia?
A. Hypokalemia
B. Increased drug clearance
C. Fluid retention
D. Hypoglycemia
What is A
Hypothermia causes diuresis and loss of electrolytes. The patient may need potassium replacement, as well as volume replacement (C). Hypothermia is associated with insulin resistance and elevated blood sugar levels (D). Hypothermia reduces the body’s ability to clear drugs (B), and patients may require lower dosages of some drugs.
A patient comes to the ED 3 days after falling down a flight of stairs while drinking at a party with pain in the left upper quadrant of the abdomen. Assessment reveals pain on palpation, and the patient is hemodynamically stable. The nurse should be most concerned about the possibility of
A. a pneumothorax.
B. a costochondritis.
C. a splenic hematoma.
D. bleeding from a liver laceration.
What is C
The spleen, located in the left upper abdominal quadrant, is the most commonly injured organ in patients with blunt abdominal trauma. Because the spleen (like the liver and kidneys) is an encapsulated organ, bleeding from the parenchyma is commonly well-contained within the capsule. Therefore, the patient remains hemodynamically stable and there is no free blood in the peritoneum. Most patients with a splenic subcapsular hematoma will heal nicely without intervention. However, the capsule can rupture, releasing blood into the abdominal cavity.
A pneumothorax is manifested by respiratory findings, costochondritis is characterized by pain with inspiration or chest palpation, and a liver laceration causes pain in the RIGHT upper abdominal quadrant.
A 60-year-old female patient presents to the emergency department with complaints of jaw pain that began 1 hour ago. The patient’s only other complaint is fatigue. Based on this information, a high priority for this patient is
A. asking the patient about dental caries.
B. obtaining an electrocardiogram.
C. asking about recent illnesses.
D. obtaining a complete set of vital signs.
What is B
This patient’s age, history of onset of jaw pain within the hour, and fatigue indicate that she may be having a myocardial infarction. Women are more likely to present with jaw, neck, or back pain than men. They are also more likely to complain of shortness of breath. Although it is appropriate to ask about dental caries (A), recent illnesses (C), and obtain vital signs (D), failure to obtain an electrocardiogram could result in delaying appropriate care
A patient taking a selective serotonin reuptake inhibitor (SSRI) for depression presents to the emergency department with agitation, tachycardia, elevated blood pressure and temperature, tremor, dry mucous membranes, and flushed diaphoretic skin after beginning to take an herbal supplement. Which herbal supplement commonly interacts with SSRIs?
A. Saw palmetto (Serenoa repens, Sabal serrulata)
B. Ginkgo (Ginkgo biloba)
C. St. John’s wort (Hypericum perforatum)
D. Valerian (Valeriana officinalis)
What is C
St. John’s wort is an herb that is used to treat depression. Both SSRIs and St. John’s wort impair serotonin reuptake and increased serotonergic activity in the central nervous system. This interaction may lead to serotonin syndrome, which can be life threatening. Symptoms include delirium, hypertension, hyperthermia, and myoclonus. Treatment includes discontinuing the drugs and supportive care, including cardiac monitoring and sedation with benzodiazepines. Saw palmetto (used to treat symptoms of benign prostatic hyperplasia) and gingko (used to improve memory) may increase bleeding risk in persons taking anticoagulants (A, B). Valerian (used to treat insomnia and anxiety) may potentiate the sedative effects of other drugs .
A woman has had lower abdominal pain and dysuria for the past 3 days. She has costovertebral tenderness on the right side, a temperature of 104°F (40°C), vomiting, and chills. The nursing priority is
A. administration of IV antibiotics.
B. administration of IV corticosteroids.
C. inserting an indwelling urinary catheter.
D. increasing the patient's oral fluid intake.
What is A
Fever, dysuria, and costovertebral tenderness are classic symptoms of pyelonephritis. Pyelonephritis, in this patient, has progressed from a urinary tract infection. IV antibiotics will be required to treat this infection.
Continuous-waveform capnography (CWC) is being used on a patient in the emergency department. You notice that the end-tidal carbon dioxide (ETco2) is 30 mm hg. Which of the following may be a reason for this reading?
A. Bronchospasm
B. Ventilation of a previously unventilated lung
C. Respiratory acidosis
D. Pulmonary embolus
What is D
Continuous-waveform capnography measures end-tidal carbon dioxide (ETco2), which is an indirect measure of pulmonary blood flow. If blood flow is blocked by a pulmonary embolus, less CO2will be exhaled. For example, ETco2 is a measure of pulmonary blood flow during cardiac arrest, and an abrupt rise in ETco2 is a sign of return of spontaneous circulation. Bronchospasm (A) ventilation of a previously unventilated lung (B), and respiratory acidosis (C) would all result in an elevated ETco2.
An 80-year-old man is admitted to the emergency department after a neighbor found him lying on the floor of his home after a fall from a stepladder. History revealed that he had been lying on the floor for approximately 9 hours. He has some bruising on the right side of his body, and xrays reveal a right hip fracture. Medications include lisinopril for hypertension and ibuprofen, which he is taking regularly for knee pain. Based on this history, in addition to the hip fracture, this patient is at high risk for which condition?
A. Spleen injury
B. Small bowel injury
C. Pancreatic injury
D. Kidney injury
What is D
This patient is at high risk for development of an acute kidney injury. The patient has several risk factors, including his age, a fall that may have directly damaged the kidney, a history of hypertension, and use of medications associated with kidney injury (lisinopril and ibuprofen). In addition, direct injury to skeletal muscles from the fall, as well as the long period of immobility, may have caused release of myoglobin from injured muscles. Injury to the spleen (A) would be more likely with an injury to the left side of the body, and injury to the small bowel (B) and pancreas (C) would be more likely with a compression injury such as from a seat belt.
A patient with Meniere disease is being discharged from the emergency department after being treated for a severe case of vertigo. When assessing the patient’s understanding of their discharge instructions, which of the following statements indicates the need for additional teaching?
A. “During an attack, I will keep my eyes closed to reduce vertigo.”
B. “I will take my medication as soon as I feel an increase in ear pressure.”
C. “I will keep my meclizine with me at all times.”
D. “After an attack, I will feel weak and off balance.”
What is A
Meniere disease results from excess endolymph in the inner ear. Signs and symptoms include pressure or fullness in the ear, tinnitus, fluctuating hearing loss that affects the lower tones, and vertigo that feels like the room is spinning. During an attack of vertigo, the patient should lie down and look straight ahead with his or her eyes focused on a fixed object. Closing the eyes may increase the spinning sensation. Patients should have their rescue medication with them at all times (C) and take it as soon as they have a warning sign of an attack coming on such as increased pressure in the ear or tinnitus (B). After an attack of vertigo, which can last 1 to 2 hours, the patient will be weak and off balance (D), and an unsteady gait may last for 1 or 2 days.
Which of the following indicates a need to clarify discharge instructions given to a patient treated for a brown recluse spider bite?
A. “I should apply a warm compress for 20 minutes 4 times a day.”
B. “I should return to the emergency department if I have joint or muscle pain.”
C. “I should report any black or blue color changes to the wound.”
D. “I will follow up with my primary care provider tomorrow.”
What is A
The patient should avoid applying heat to the site of a brown recluse spider bite because heat could cause the venom to spread and increase tissue destruction. The patient can continue to apply intermittent ice to the site. The other responses are correct.
Which of the following signs is an early indication that the condition of a patient with a ruptured diaphragm is deteriorating?
A. Oxygen saturation declines.
B. QRS complex widens by 50%.
C. Bowel sounds are heard in the chest.
D. Pulse pressure narrows.
What is A
In diaphragmatic rupture, abdominal contents spill into the thoracic cavity, causing respiratory compromise secondary to lung compression. Oxygen saturation decreases as a result. Bowel sounds heard in the chest would be expected and pulse pressure narrowing is a late sign.
A patient with hemophilia type A requires factor VIII replacement. The hematologist orders a dose of 25 units/kg plus or minus 10%. The hospital has 250-, 500-, and 1,000-unit vials on hand. The pharmacy sends a 500-unit vial containing 564 units of factor VIII and a 1,000-unit vial containing 1,173 units of factor VIII. The patient weighs 70 kg. The nurse would
A. Question the order for plus or minus 10%.
B. Administer the dose sent from the pharmacy.
C. Request an additional 250-unit vial and waste the unused portion.
D. Request an additional 250-unit vial and return the unused portion to the pharmacy.
What is B
Doses of factor VIII are usually prescribed within a range because of the high cost. Although vials are available in doses of 250, 500, or 1,000 units, the vials generally do not contain these exact amounts of factor VIII. To avoid wastage, hematologists may order the dose within a range. Factor VIII is provided in single-dose vials and must be administered soon after the factor is reconstituted; thus, returning the drug to the pharmacy would not be feasible.