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Which of the following interventions is MOST likely indicated for a patient presenting with a palpable right upper quadrant sausage-shaped mass, tachycardia, fever, and passing currant jelly stool?
Detailed Rationale
The presentation is classic for intussusception in a child (though not age-specified). The sausage-shaped mass, currant jelly stool (blood and mucus), and systemic signs indicate bowel ischemia. A barium or air enema is both diagnostic and often therapeutic, as it can reduce the intussusception. Surgery is indicated if enema fails or peritonitis is present.
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A patient with a history of diverticulitis is being discharged from the emergency department after being evaluated for abdominal pain. Which statement would indicate that discharge teaching has been effective?
Detailed Rationale
Long-term management of diverticular disease focuses on preventing future attacks. A high-fiber diet softens stool, decreases intracolonic pressure, and may prevent the formation or inflammation of diverticula. While NSAIDs like ibuprofen are often avoided during acute episodes, the core preventative measure is dietary fiber increase.
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A patient with pericarditis is given oxygen, ibuprofen, and IV antibiotics. Which of the following BEST indicates that the patient is responding to this treatment?
Detailed Rationale
A hallmark of pericarditis is positional pain that is worse when lying supine and relieved by sitting up and leaning forward. Therefore, the patient's ability to tolerate a supine position without pain is a strong indicator that the inflammatory process is subsiding with treatment.
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A middle-aged woman has abdominal pain, nausea, and vomiting. Cholecystitis would be suspected if the patient also has
Detailed Rationale
Cholecystitis (gallbladder inflammation) often causes pain in the right upper quadrant or epigastrium that may radiate to the back or shoulder. Jaundice can occur if a gallstone obstructs the common bile duct (choledocholithiasis). Fever is common, but melena (black, tarry stool) is not typical.
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A patient with an open fracture of the humerus is being prepared for air medical transport. The MOST appropriate stabilization of the fracture is to apply
Detailed Rationale
For transport, especially air transport where space is limited and swelling can increase with altitude changes, a well-padded posterior splint provides effective stabilization without the circumferential restriction of a cast. An air splint is less ideal for long bone fractures and may not provide enough support.
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Prior to the transfer of a patient from the emergency department to another hospital
Detailed Rationale
The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that a receiving physician (or their designee) accept the patient in transfer before the transfer occurs. This ensures the receiving facility has the capability and capacity to care for the patient.
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Drainage of cerebrospinal fluid from the ear is MOST commonly associated with
Detailed Rationale
CSF otorrhea (drainage from the ear) is a classic sign of a basilar skull fracture, which involves the bones at the base of the skull (temporal bone). The fracture tears the dura, allowing CSF to leak through the ear canal. Rhinorrhea (from the nose) can also occur.
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ST segment elevation in leads II, III, and aVF on an ECG indicates ischemia in what area of the heart?
Detailed Rationale
The inferior wall of the heart is supplied by the right coronary artery (RCA). Leads II, III, and aVF are the inferior leads. ST elevation in these leads indicates an acute inferior wall myocardial infarction.
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A patient presents with confusion, tachycardia, tachypnea, and labored breathing. During assessment, the patient states that they recently had their furnace serviced. A nurse should immediately
Detailed Rationale
The history suggests potential carbon monoxide (CO) poisoning from a malfunctioning furnace. CO binds to hemoglobin, displacing oxygen. The immediate, most critical intervention is to administer 100% oxygen via a non-rebreather mask to competitively displace CO from hemoglobin and reduce its half-life.
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A patient with a cultural prohibition is refusing blood products after critical post-partum hemorrhaging. The patient has been informed of the risks of refusal, including probable death, and continues to refuse. The patient's husband is demanding administration of blood products. The nurse's PRIORITY is to
Detailed Rationale
The foundational ethical and legal principle is patient autonomy. The nurse's first priority is to ensure the patient has decision-making capacity (is alert, oriented, and understands the risks/benefits). If she is competent, her refusal must be honored, regardless of family wishes. The situation should be escalated to supervisors and ethics.
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A patient presents with penetrating trauma requiring the use of resuscitative endovascular balloon occlusion of the aorta (REBOA). The nurse should recognize that REBOA is an alternative to
Detailed Rationale
REBOA is a minimally invasive procedure where a balloon is inserted into the aorta (via the femoral artery) and inflated to temporarily control non-compressible truncal hemorrhage. It is an alternative to emergency department thoracotomy with aortic cross-clamping, which is a highly invasive open procedure.
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A patient is being discharged with renal calculi. Which of the following statements from the patient demonstrates that discharge instructions have been effective?
Detailed Rationale
Spinach is high in oxalate. For calcium oxalate stones (the most common type), dietary counseling often includes limiting high-oxalate foods (like spinach, nuts, chocolate) to reduce stone recurrence. Increasing fluids is key; decreasing fluids is incorrect. Milk in moderation is usually fine.
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A patient with gout has undergone aspiration of a painful joint. Which of the following would MOST likely be found in the laboratory analysis of the synovial fluid?
Detailed Rationale
Gout is caused by the deposition of monosodium urate crystals in joints. Synovial fluid analysis in gout typically reveals needle-shaped, negatively birefringent crystals under polarized light, along with inflammatory cells. Septic arthritis would show bacteria.
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Which of the following findings may be present in a patient who is experiencing cyanide poisoning?
Detailed Rationale
Cyanide poisoning can sometimes be associated with a characteristic smell of bitter almonds on the patient's breath. However, the ability to detect this odor is genetically determined (many people cannot smell it). Soapy mucous membranes are associated with fluoride poisoning. Swelling and salivation are not typical.
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During insertion of a subclavian catheter, a patient's respirations increase to 35 breaths/min, and the heart rate increases to 110 beats/min. A nurse should suspect a
Detailed Rationale
Tachypnea and tachycardia are early signs of a pneumothorax, a known complication of subclavian vein catheterization. The needle can inadvertently puncture the lung apex, allowing air to enter the pleural space. Hemothorax would also cause distress but might present with signs of shock.
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A patient with chemical burns on 25% of the total body surface area presents to the emergency department. PRIORITY intervention should be to
Detailed Rationale
The immediate priority with any chemical burn is to stop the ongoing tissue damage. This is done by copious, prolonged irrigation with water or saline to dilute and remove the chemical. Neutralizing agents are generally avoided as the heat from the neutralization reaction can cause further injury. Wound dressing/cream application comes later.
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An elderly patient presents with shortness of breath but denies any pain. The nurse should FIRST
Detailed Rationale
In an elderly patient, shortness of breath (dyspnea) is a common equivalent symptom for myocardial infarction (MI), especially in those with diabetes or neuropathy who may not feel typical chest pain. Obtaining an ECG is the fastest way to identify an acute coronary syndrome, which would require immediate intervention.
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A 25-year-old female who is afebrile presents with right-sided lower abdominal pain that worsens with sexual intercourse. Her last menstrual period was approximately 2 weeks ago, and she denies any current vaginal bleeding or abnormal discharge. The nurse should suspect
Detailed Rationale
The presentation (mid-cycle pain, afebrile, pain with intercourse - dyspareunia) is classic for mittelschmerz or a ruptured ovarian cyst. Pain at ovulation (~2 weeks after LMP) is common. A ruptured cyst causes sudden, unilateral lower abdominal pain. Ectopic pregnancy typically presents with vaginal bleeding and a missed period. Ovarian torsion is sudden, severe, and often associated with nausea/vomiting. Appendicitis pain usually starts periumbilical and migrates to RLQ, and is often associated with fever and anorexia.
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A patient with an acute myocardial infarction is treated with a fibrinolytic (thrombolytic) agent. Six hours later, the patient has a sudden severe headache above the left eye. The MOST likely cause of the headache is
Detailed Rationale
A sudden, severe headache after fibrinolytic therapy is a major red flag for intracranial hemorrhage, a known and serious complication of thrombolytics. This is a neurologic emergency. While nitroglycerin can cause headaches, they are usually diffuse and not sudden/severe. Sinusitis and brain tumor headaches are not typically acute onset in this context.
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Which of the following patients is at HIGHEST risk for developing a pulmonary embolism?
Detailed Rationale
This patient combines multiple high-risk factors for venous thromboembolism (VTE) and PE: pregnancy (increased clotting factors, venous stasis), late trimester (highest risk), and bedrest (immobility). While post-op patients are at risk, the 24-hour mark is very early. Post-cardiac surgery patients are at risk, but 3 weeks out is less acute. A patient with atrial fibrillation on anticoagulants is protected from clot formation related to the arrhythmia.
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After 30 seconds of adequate assisted ventilation of a 19-day old neonate, the nurse notes the heart rate is 58 beats/min. The nurse should NEXT
Detailed Rationale
According to neonatal resuscitation guidelines, if the heart rate remains below 60 bpm after 30 seconds of adequate positive-pressure ventilation, the next step is to initiate chest compressions. This is a critical threshold. Warming and stimulation are earlier steps. Atropine is not part of neonatal bradycardia/arrest algorithms.
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Following facial laceration repair, discharge teaching should include instructing patients to apply
Detailed Rationale
To minimize scarring and hyperpigmentation, especially on the face, patients should be instructed to apply sunblock (SPF 30 or higher) to the healed wound area for at least 6 months to a year. New skin is very sensitive to UV rays. Steroidal ointments are not routinely used. Ice is for initial edema control. Povidone-iodine can be irritating and is not for routine wound care after repair.
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Pregnancy after sexual assault may be prevented by
Detailed Rationale
Emergency contraception is a critical component of post-sexual assault care. Progestin-only emergency contraceptive pills (like levonorgestrel) are highly effective at preventing pregnancy if taken within 72-120 hours. Douching is ineffective and not recommended. Spermicide alone is not reliable post-assault. Antibiotics are for STI prophylaxis, not contraception.
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When caring for a patient with a steam inhalation injury, a nurse should immediately
Detailed Rationale
Steam inhalation carries a high risk of upper airway edema and thermal injury to the mucosa. This swelling can progress rapidly and cause complete airway obstruction. The nurse's immediate priority is to anticipate and prepare for prophylactic or early endotracheal intubation to secure the airway before it becomes impossible. IV access and pain management are important but secondary to airway. A chest X-ray may be done but is not the immediate action.
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A child is suspected to have epiglottitis. A nurse should
Detailed Rationale
In suspected epiglottitis, the priority is to keep the child calm and avoid any procedures that may cause agitation, crying, or struggling, as this can precipitate complete airway obstruction. The child should be allowed to remain in a position of comfort (often sitting up, leaning forward). Throat examination or culture is contraindicated. IV access and other interventions should be deferred until the airway is secured in a controlled setting (e.g., OR).
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A patient presents with history of fever, weight loss, and a persistent cough for the past week. The nurse should IMMEDIATELY
Detailed Rationale
The combination of fever, weight loss, and persistent cough is highly suggestive of tuberculosis (TB) until proven otherwise. To protect staff and other patients, the nurse's immediate action should be to place the patient on airborne precautions (negative pressure room, N95 respirator). This is an infection control priority. Diagnostic tests (CXR, cultures) and treatment follow. Antibiotics should not be given before appropriate diagnostics for TB.
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The following is obtained on a patient who had a seizure and is receiving phenytoin (Dilantin) IV: A nurse should FIRST
Detailed Rationale
The ECG demonstrates a ventricular conduction abnormality in a patient receiving IV phenytoin, a medication known to have cardiotoxic effects when administered intravenously, including hypotension, bradycardia, and ventricular dysrhythmias. The priority nursing action is to immediately discontinue the phenytoin infusion to prevent further cardiac compromise. Treating the dysrhythmia without stopping the causative agent would allow continued myocardial irritation. Therefore, removing the offending medication is the safest and most appropriate initial intervention.
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Epidural hemorrhage following head trauma should be suspected if the patient
Detailed Rationale
Epidural hematoma classically presents with a 'lucid interval' a period of consciousness after the initial trauma, followed by a rapid decline in mental status as the hematoma expands and causes increased intracranial pressure. This pattern is a hallmark. Increasing confusion weeks later suggests subdural hematoma. Hypotension is not specific. Persistent LOC suggests severe diffuse injury or other intracranial hemorrhage.
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A patient returns to the emergency department for a wound check after treatment of multiple abrasions. Which of the following is considered an adverse finding?
Detailed Rationale
Permanent tattooing' refers to dirt or debris that becomes embedded in the dermis during an abrasion ('road rash'). If not thoroughly scrubbed out during initial wound care, the debris will be sealed in as the epithelium heals over it, resulting in permanent discoloration of the skin. This is considered a poor cosmetic outcome and an adverse finding indicating inadequate initial cleansing. Blood in tissue (ecchymosis) and serous drainage are expected. Exposed dermis is the nature of an abrasion.
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A patient presents with a fever, night sweats, and cough. Which of the following increases the patient's risk for tuberculosis?
Detailed Rationale
(Same rationale as question 112) Tuberculosis spreads in close-contact settings. Nursing home residency is a significant risk factor due to congregate living and potential for airborne transmission from an undiagnosed case. Smoking, pneumonia history, and asbestos exposure (linked to lung cancer) are not primary risk factors for acquiring TB.
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Several victims of an airplane crash arrive in the emergency department. The injuries of a patient who is conscious, crying, and has paralysis and paresthesia from the waist down should be classified as
Detailed Rationale
Paralysis and paresthesia from the waist down indicate a possible spinal cord injury. While not causing immediate hemorrhage, a spinal cord injury is considered life-threatening due to the risk of respiratory compromise (if the injury ascends), neurogenic shock, and permanent disability. It requires immediate assessment and intervention (imaging, spinal stabilization, possible steroids/surgery) and would be triaged as high priority (e.g., Red/Immediate in a mass casualty incident). It is not 'fatal even if treated' and should not be deferred.
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The eye injury that requires the MOST prolonged and thorough irrigation is caused by
Detailed Rationale
Alkali substances (e.g., lye, lime, ammonia) are particularly dangerous because they saponify lipids and penetrate deeply into ocular tissues, causing ongoing damage. Irrigation must be prolonged (often for 30-60 minutes or more, litmus paper testing of tears until neutral) to ensure complete removal. Acids tend to coagulate proteins, creating a barrier that limits deeper penetration. Thermal and flash burns do not require the same degree of chemical decontamination.
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Which of the following patients should receive the HIGHEST triage priority?
Detailed Rationale
In pediatric triage, the very young infant (<1-2 months) with a fever is a HIGHEST priority due to the risk of serious bacterial infection (sepsis, meningitis) and their limited physiological reserves. A 20-day-old with fever and decreased feeding requires immediate evaluation and sepsis workup. A forearm deformity is urgent but not immediately life-threatening. A resolved febrile seizure in a well-appearing child is lower acuity. An 8-year-old with dehydration is serious but can be triaged after the febrile neonate.
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Which of the following illnesses is associated with the GREATEST risk for gastritis?
Detailed Rationale
Gastritis, specifically hemorrhagic or erosive gastritis, is a well-known complication of severe congestive heart failure (CHF). In CHF, venous congestion occurs throughout the body, including the gastric mucosa. This leads to mucosal edema, reduced blood flow, and impaired mucosal barrier function, making it more susceptible to injury and ulceration. While other conditions like renal insufficiency can cause uremic gastritis, and chronic anxiety is linked to stress-related mucosal damage, the association is strongest and most direct with CHF due to the hemodynamic compromise.
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The infectious period for hepatitis A is
Detailed Rationale
Hepatitis A virus is most contagious during the 1-2 weeks BEFORE the onset of jaundice or clinical symptoms, when the viral load in the stool is highest. The infectivity decreases rapidly after liver function abnormalities appear and jaundice sets in. The patient is generally considered non-infectious about one week after the onset of jaundice. Therefore, the period of greatest risk of transmission is when the patient is asymptomatic or has vague symptoms.
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A patient comes to the emergency department after an argument. The patient is lightheaded, has tingling around the mouth, and complains of difficulty breathing. The patient’s vital signs are: BP 130/70 mm Hg, HR 110 beats/min, RR 32 breaths/min, T 97° F (36.1° C). A nurse should FIRST
Detailed Rationale
The clinical picture (post-argument, lightheadedness, perioral tingling, tachypnea, normal BP/O2 sat) is classic for hyperventilation syndrome, often triggered by anxiety. The FIRST and most therapeutic intervention is to provide calm reassurance and coach the patient to slow their breathing. Breathing into a paper bag is an outdated and potentially dangerous intervention as it can cause hypoxia, especially if the diagnosis is incorrect (e.g., asthma, PE). ABGs may be obtained later to confirm respiratory alkalosis but are not the first action. Medication (e.g., anxiolytics) might be considered later if reassurance is ineffective.
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Which of the following signs and symptoms would a patient with labyrinthitis MOST likely exhibit?
Detailed Rationale
Labyrinthitis is an inflammation of the inner ear (labyrinth), typically viral, that disrupts vestibular function. The hallmark symptoms are acute, severe vertigo (a spinning sensation) and nystagmus (involuntary eye movements). Nausea and vomiting are common associated symptoms due to the vertigo. Purulent drainage indicates otitis externa or media, not isolated labyrinthitis. Severe headache is not a primary feature.
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Triage of a 70-year-old man who has an acute onset of a severe headache will be MOST affected by which of the following factors?
Detailed Rationale
In triage, the goal is to identify life-threatening conditions. An acute severe headache in an older adult raises concern for an intracranial hemorrhage (e.g., subdural, intracerebral). Current use of warfarin, an anticoagulant, significantly increases the risk and severity of such bleeds. This factor would immediately elevate the patient's triage acuity. Photophobia is associated with migraines or meningitis but is not as high-risk an indicator as anticoagulation. Depression and digoxin use are less directly related to acute headache emergencies.
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A patient involved in a high-speed motor vehicle crash has an initial blood pressure of 165/89 mm Hg and a heart rate of 110 beats/min. Reassessment reveals the patient is now cool and clammy with an altered mental status and jugular vein distention. The blood pressure has dropped to 80/40 mm Hg and the heart rate is 122 beats/min. The MOST likely reason for this change is
Detailed Rationale
This presentation describes Beck's triad (hypotension, JVD, muffled heart sounds - though not listed) and pulsus paradoxus, which is classic for pericardial tamponade. In tamponade, fluid in the pericardial sac compresses the heart, impairing filling and causing a precipitous drop in cardiac output. The initial normal BP may represent a 'lucid interval' or compensated state. The combination of hypotension, JVD (indicative of elevated central venous pressure), and tachycardia in a trauma patient is highly suggestive. Transtentorial herniation causes neurological changes and Cushing's triad (hypertension, bradycardia, irregular respirations). Diaphragmatic rupture and flail chest primarily cause respiratory distress.
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A crying 4-year-old boy presents with significant foreskin edema. A nurse should prepare the child for
Detailed Rationale
This describes paraphimosis, a urologic emergency where the retracted foreskin cannot be returned to its normal position, causing constriction and edema of the glans. The priority intervention is manual reduction, which involves gentle compression of the edematous glans and foreskin and then pulling the foreskin forward. Looking for a constricting hair or thread (a 'hair tourniquet') is part of the assessment, especially in infants. If manual reduction fails, emergency dorsal slit procedure may be needed. Imaging and lab work are not first-line for this clear clinical diagnosis.
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The individual MOST likely to commit suicide is the one who
Detailed Rationale
While all factors are associated with suicide risk, the presence of a specific, lethal plan is one of the strongest predictors of imminent suicide. It moves beyond ideation or general risk factors to concrete intent and means. The other options describe common risk factors or correlates, but a detailed plan with high lethality indicates a higher level of immediate danger.
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A patient involved in an assault sustains a karate-type blow to the neck. Hoarseness and dyspnea are noted. A nurse should suspect
Detailed Rationale
A direct blunt blow to the anterior neck (a 'clothesline' or karate chop injury) can fracture the laryngeal cartilage (thyroid or cricoid). Signs of laryngeal fracture include hoarseness/voice change, dyspnea/stridor, subcutaneous emphysema (crepitus), and tenderness over the larynx. This is an airway emergency. Vocal cord paralysis is more gradual or post-surgical. Tracheal stenosis is a chronic condition. Trauma to the distal bronchus is associated with major chest trauma, not an isolated neck blow.
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Which of the following is MOST consistent with an abusive situation?
Detailed Rationale
In suspected abuse, certain patterns are red flags. For a toddler, bruises on bilateral lower legs in varying stages of healing are highly suspicious for non-accidental trauma (e.g., repeated grabbing, shaking). Toddlers do get bruises on their shins from falls, but bilateral, multiple-stage bruises are concerning. A teenager with a mandible fracture from a fight may or may not be abuse. An elderly patient reporting financial/medication withholding is a sign of potential elder abuse. A fall in a nursing home could be accidental or neglectful. The toddler's bruising pattern is the most classic physical finding of abuse among the options.
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A patient who has received facial sutures should be instructed to have the sutures removed in how many days?
Detailed Rationale
Facial skin has an excellent blood supply and heals quickly. To minimize scarring, sutures on the face are typically removed in 3 to 5 days. Leaving them in longer increases the risk of suture marks ('track marks'). Sutures on other body parts (e.g., extremities, trunk) are left in longer (7-14 days) due to slower healing and higher tension.
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A patient with anorexia nervosa presents complaining of muscle weakness and cramps. A nurse should anticipate the need for
Detailed Rationale
Patients with severe anorexia nervosa are at extreme risk for electrolyte imbalances due to malnutrition and purging behaviors. Hypokalemia, hypophosphatemia, and hypomagnesemia are common and can cause muscle weakness, cramps, and, most critically, life-threatening cardiac arrhythmias (e.g., prolonged QT interval, torsades de pointes). Therefore, cardiac monitoring is essential. Fluids may be needed but must be given cautiously (risk of refeeding syndrome). Muscle relaxants and NSAIDs do not address the underlying electrolyte disturbance.
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Which of the following interventions is MOST likely indicated for a patient presenting with a palpable right upper quadrant sausage-shaped mass, tachycardia, fever, and passing currant jelly stool?
Detailed Rationale
The presentation is classic for intussusception in a child (though not age-specified). The sausage-shaped mass, currant jelly stool (blood and mucus), and systemic signs indicate bowel ischemia. A barium or air enema is both diagnostic and often therapeutic, as it can reduce the intussusception. Surgery is indicated if enema fails or peritonitis is present.
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A patient with a history of diverticulitis is being discharged from the emergency department after being evaluated for abdominal pain. Which statement would indicate that discharge teaching has been effective?
Detailed Rationale
Long-term management of diverticular disease focuses on preventing future attacks. A high-fiber diet softens stool, decreases intracolonic pressure, and may prevent the formation or inflammation of diverticula. While NSAIDs like ibuprofen are often avoided during acute episodes, the core preventative measure is dietary fiber increase.
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A patient with pericarditis is given oxygen, ibuprofen, and IV antibiotics. Which of the following BEST indicates that the patient is responding to this treatment?
Detailed Rationale
A hallmark of pericarditis is positional pain that is worse when lying supine and relieved by sitting up and leaning forward. Therefore, the patient's ability to tolerate a supine position without pain is a strong indicator that the inflammatory process is subsiding with treatment.
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A middle-aged woman has abdominal pain, nausea, and vomiting. Cholecystitis would be suspected if the patient also has
Detailed Rationale
Cholecystitis (gallbladder inflammation) often causes pain in the right upper quadrant or epigastrium that may radiate to the back or shoulder. Jaundice can occur if a gallstone obstructs the common bile duct (choledocholithiasis). Fever is common, but melena (black, tarry stool) is not typical.
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A patient with an open fracture of the humerus is being prepared for air medical transport. The MOST appropriate stabilization of the fracture is to apply
Detailed Rationale
For transport, especially air transport where space is limited and swelling can increase with altitude changes, a well-padded posterior splint provides effective stabilization without the circumferential restriction of a cast. An air splint is less ideal for long bone fractures and may not provide enough support.
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Prior to the transfer of a patient from the emergency department to another hospital
Detailed Rationale
The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that a receiving physician (or their designee) accept the patient in transfer before the transfer occurs. This ensures the receiving facility has the capability and capacity to care for the patient.
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Drainage of cerebrospinal fluid from the ear is MOST commonly associated with
Detailed Rationale
CSF otorrhea (drainage from the ear) is a classic sign of a basilar skull fracture, which involves the bones at the base of the skull (temporal bone). The fracture tears the dura, allowing CSF to leak through the ear canal. Rhinorrhea (from the nose) can also occur.
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ST segment elevation in leads II, III, and aVF on an ECG indicates ischemia in what area of the heart?
Detailed Rationale
The inferior wall of the heart is supplied by the right coronary artery (RCA). Leads II, III, and aVF are the inferior leads. ST elevation in these leads indicates an acute inferior wall myocardial infarction.
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A patient presents with confusion, tachycardia, tachypnea, and labored breathing. During assessment, the patient states that they recently had their furnace serviced. A nurse should immediately
Detailed Rationale
The history suggests potential carbon monoxide (CO) poisoning from a malfunctioning furnace. CO binds to hemoglobin, displacing oxygen. The immediate, most critical intervention is to administer 100% oxygen via a non-rebreather mask to competitively displace CO from hemoglobin and reduce its half-life.
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A patient with a cultural prohibition is refusing blood products after critical post-partum hemorrhaging. The patient has been informed of the risks of refusal, including probable death, and continues to refuse. The patient's husband is demanding administration of blood products. The nurse's PRIORITY is to
Detailed Rationale
The foundational ethical and legal principle is patient autonomy. The nurse's first priority is to ensure the patient has decision-making capacity (is alert, oriented, and understands the risks/benefits). If she is competent, her refusal must be honored, regardless of family wishes. The situation should be escalated to supervisors and ethics.
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A patient presents with penetrating trauma requiring the use of resuscitative endovascular balloon occlusion of the aorta (REBOA). The nurse should recognize that REBOA is an alternative to
Detailed Rationale
REBOA is a minimally invasive procedure where a balloon is inserted into the aorta (via the femoral artery) and inflated to temporarily control non-compressible truncal hemorrhage. It is an alternative to emergency department thoracotomy with aortic cross-clamping, which is a highly invasive open procedure.
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A patient is being discharged with renal calculi. Which of the following statements from the patient demonstrates that discharge instructions have been effective?
Detailed Rationale
Spinach is high in oxalate. For calcium oxalate stones (the most common type), dietary counseling often includes limiting high-oxalate foods (like spinach, nuts, chocolate) to reduce stone recurrence. Increasing fluids is key; decreasing fluids is incorrect. Milk in moderation is usually fine.
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A patient with gout has undergone aspiration of a painful joint. Which of the following would MOST likely be found in the laboratory analysis of the synovial fluid?
Detailed Rationale
Gout is caused by the deposition of monosodium urate crystals in joints. Synovial fluid analysis in gout typically reveals needle-shaped, negatively birefringent crystals under polarized light, along with inflammatory cells. Septic arthritis would show bacteria.
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Which of the following findings may be present in a patient who is experiencing cyanide poisoning?
Detailed Rationale
Cyanide poisoning can sometimes be associated with a characteristic smell of bitter almonds on the patient's breath. However, the ability to detect this odor is genetically determined (many people cannot smell it). Soapy mucous membranes are associated with fluoride poisoning. Swelling and salivation are not typical.
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During insertion of a subclavian catheter, a patient's respirations increase to 35 breaths/min, and the heart rate increases to 110 beats/min. A nurse should suspect a
Detailed Rationale
Tachypnea and tachycardia are early signs of a pneumothorax, a known complication of subclavian vein catheterization. The needle can inadvertently puncture the lung apex, allowing air to enter the pleural space. Hemothorax would also cause distress but might present with signs of shock.
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A patient with chemical burns on 25% of the total body surface area presents to the emergency department. PRIORITY intervention should be to
Detailed Rationale
The immediate priority with any chemical burn is to stop the ongoing tissue damage. This is done by copious, prolonged irrigation with water or saline to dilute and remove the chemical. Neutralizing agents are generally avoided as the heat from the neutralization reaction can cause further injury. Wound dressing/cream application comes later.
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An elderly patient presents with shortness of breath but denies any pain. The nurse should FIRST
Detailed Rationale
In an elderly patient, shortness of breath (dyspnea) is a common equivalent symptom for myocardial infarction (MI), especially in those with diabetes or neuropathy who may not feel typical chest pain. Obtaining an ECG is the fastest way to identify an acute coronary syndrome, which would require immediate intervention.
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A 25-year-old female who is afebrile presents with right-sided lower abdominal pain that worsens with sexual intercourse. Her last menstrual period was approximately 2 weeks ago, and she denies any current vaginal bleeding or abnormal discharge. The nurse should suspect
Detailed Rationale
The presentation (mid-cycle pain, afebrile, pain with intercourse - dyspareunia) is classic for mittelschmerz or a ruptured ovarian cyst. Pain at ovulation (~2 weeks after LMP) is common. A ruptured cyst causes sudden, unilateral lower abdominal pain. Ectopic pregnancy typically presents with vaginal bleeding and a missed period. Ovarian torsion is sudden, severe, and often associated with nausea/vomiting. Appendicitis pain usually starts periumbilical and migrates to RLQ, and is often associated with fever and anorexia.
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A patient with an acute myocardial infarction is treated with a fibrinolytic (thrombolytic) agent. Six hours later, the patient has a sudden severe headache above the left eye. The MOST likely cause of the headache is
Detailed Rationale
A sudden, severe headache after fibrinolytic therapy is a major red flag for intracranial hemorrhage, a known and serious complication of thrombolytics. This is a neurologic emergency. While nitroglycerin can cause headaches, they are usually diffuse and not sudden/severe. Sinusitis and brain tumor headaches are not typically acute onset in this context.
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Which of the following patients is at HIGHEST risk for developing a pulmonary embolism?
Detailed Rationale
This patient combines multiple high-risk factors for venous thromboembolism (VTE) and PE: pregnancy (increased clotting factors, venous stasis), late trimester (highest risk), and bedrest (immobility). While post-op patients are at risk, the 24-hour mark is very early. Post-cardiac surgery patients are at risk, but 3 weeks out is less acute. A patient with atrial fibrillation on anticoagulants is protected from clot formation related to the arrhythmia.
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After 30 seconds of adequate assisted ventilation of a 19-day old neonate, the nurse notes the heart rate is 58 beats/min. The nurse should NEXT
Detailed Rationale
According to neonatal resuscitation guidelines, if the heart rate remains below 60 bpm after 30 seconds of adequate positive-pressure ventilation, the next step is to initiate chest compressions. This is a critical threshold. Warming and stimulation are earlier steps. Atropine is not part of neonatal bradycardia/arrest algorithms.
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Following facial laceration repair, discharge teaching should include instructing patients to apply
Detailed Rationale
To minimize scarring and hyperpigmentation, especially on the face, patients should be instructed to apply sunblock (SPF 30 or higher) to the healed wound area for at least 6 months to a year. New skin is very sensitive to UV rays. Steroidal ointments are not routinely used. Ice is for initial edema control. Povidone-iodine can be irritating and is not for routine wound care after repair.
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Pregnancy after sexual assault may be prevented by
Detailed Rationale
Emergency contraception is a critical component of post-sexual assault care. Progestin-only emergency contraceptive pills (like levonorgestrel) are highly effective at preventing pregnancy if taken within 72-120 hours. Douching is ineffective and not recommended. Spermicide alone is not reliable post-assault. Antibiotics are for STI prophylaxis, not contraception.
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When caring for a patient with a steam inhalation injury, a nurse should immediately
Detailed Rationale
Steam inhalation carries a high risk of upper airway edema and thermal injury to the mucosa. This swelling can progress rapidly and cause complete airway obstruction. The nurse's immediate priority is to anticipate and prepare for prophylactic or early endotracheal intubation to secure the airway before it becomes impossible. IV access and pain management are important but secondary to airway. A chest X-ray may be done but is not the immediate action.
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A child is suspected to have epiglottitis. A nurse should
Detailed Rationale
In suspected epiglottitis, the priority is to keep the child calm and avoid any procedures that may cause agitation, crying, or struggling, as this can precipitate complete airway obstruction. The child should be allowed to remain in a position of comfort (often sitting up, leaning forward). Throat examination or culture is contraindicated. IV access and other interventions should be deferred until the airway is secured in a controlled setting (e.g., OR).
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A patient presents with history of fever, weight loss, and a persistent cough for the past week. The nurse should IMMEDIATELY
Detailed Rationale
The combination of fever, weight loss, and persistent cough is highly suggestive of tuberculosis (TB) until proven otherwise. To protect staff and other patients, the nurse's immediate action should be to place the patient on airborne precautions (negative pressure room, N95 respirator). This is an infection control priority. Diagnostic tests (CXR, cultures) and treatment follow. Antibiotics should not be given before appropriate diagnostics for TB.
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The following is obtained on a patient who had a seizure and is receiving phenytoin (Dilantin) IV: A nurse should FIRST
Detailed Rationale
The ECG demonstrates a ventricular conduction abnormality in a patient receiving IV phenytoin, a medication known to have cardiotoxic effects when administered intravenously, including hypotension, bradycardia, and ventricular dysrhythmias. The priority nursing action is to immediately discontinue the phenytoin infusion to prevent further cardiac compromise. Treating the dysrhythmia without stopping the causative agent would allow continued myocardial irritation. Therefore, removing the offending medication is the safest and most appropriate initial intervention.
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Epidural hemorrhage following head trauma should be suspected if the patient
Detailed Rationale
Epidural hematoma classically presents with a 'lucid interval' a period of consciousness after the initial trauma, followed by a rapid decline in mental status as the hematoma expands and causes increased intracranial pressure. This pattern is a hallmark. Increasing confusion weeks later suggests subdural hematoma. Hypotension is not specific. Persistent LOC suggests severe diffuse injury or other intracranial hemorrhage.
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A patient returns to the emergency department for a wound check after treatment of multiple abrasions. Which of the following is considered an adverse finding?
Detailed Rationale
Permanent tattooing' refers to dirt or debris that becomes embedded in the dermis during an abrasion ('road rash'). If not thoroughly scrubbed out during initial wound care, the debris will be sealed in as the epithelium heals over it, resulting in permanent discoloration of the skin. This is considered a poor cosmetic outcome and an adverse finding indicating inadequate initial cleansing. Blood in tissue (ecchymosis) and serous drainage are expected. Exposed dermis is the nature of an abrasion.
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A patient presents with a fever, night sweats, and cough. Which of the following increases the patient's risk for tuberculosis?
Detailed Rationale
(Same rationale as question 112) Tuberculosis spreads in close-contact settings. Nursing home residency is a significant risk factor due to congregate living and potential for airborne transmission from an undiagnosed case. Smoking, pneumonia history, and asbestos exposure (linked to lung cancer) are not primary risk factors for acquiring TB.
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Several victims of an airplane crash arrive in the emergency department. The injuries of a patient who is conscious, crying, and has paralysis and paresthesia from the waist down should be classified as
Detailed Rationale
Paralysis and paresthesia from the waist down indicate a possible spinal cord injury. While not causing immediate hemorrhage, a spinal cord injury is considered life-threatening due to the risk of respiratory compromise (if the injury ascends), neurogenic shock, and permanent disability. It requires immediate assessment and intervention (imaging, spinal stabilization, possible steroids/surgery) and would be triaged as high priority (e.g., Red/Immediate in a mass casualty incident). It is not 'fatal even if treated' and should not be deferred.
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The eye injury that requires the MOST prolonged and thorough irrigation is caused by
Detailed Rationale
Alkali substances (e.g., lye, lime, ammonia) are particularly dangerous because they saponify lipids and penetrate deeply into ocular tissues, causing ongoing damage. Irrigation must be prolonged (often for 30-60 minutes or more, litmus paper testing of tears until neutral) to ensure complete removal. Acids tend to coagulate proteins, creating a barrier that limits deeper penetration. Thermal and flash burns do not require the same degree of chemical decontamination.
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Which of the following patients should receive the HIGHEST triage priority?
Detailed Rationale
In pediatric triage, the very young infant (<1-2 months) with a fever is a HIGHEST priority due to the risk of serious bacterial infection (sepsis, meningitis) and their limited physiological reserves. A 20-day-old with fever and decreased feeding requires immediate evaluation and sepsis workup. A forearm deformity is urgent but not immediately life-threatening. A resolved febrile seizure in a well-appearing child is lower acuity. An 8-year-old with dehydration is serious but can be triaged after the febrile neonate.
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Which of the following illnesses is associated with the GREATEST risk for gastritis?
Detailed Rationale
Gastritis, specifically hemorrhagic or erosive gastritis, is a well-known complication of severe congestive heart failure (CHF). In CHF, venous congestion occurs throughout the body, including the gastric mucosa. This leads to mucosal edema, reduced blood flow, and impaired mucosal barrier function, making it more susceptible to injury and ulceration. While other conditions like renal insufficiency can cause uremic gastritis, and chronic anxiety is linked to stress-related mucosal damage, the association is strongest and most direct with CHF due to the hemodynamic compromise.
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The infectious period for hepatitis A is
Detailed Rationale
Hepatitis A virus is most contagious during the 1-2 weeks BEFORE the onset of jaundice or clinical symptoms, when the viral load in the stool is highest. The infectivity decreases rapidly after liver function abnormalities appear and jaundice sets in. The patient is generally considered non-infectious about one week after the onset of jaundice. Therefore, the period of greatest risk of transmission is when the patient is asymptomatic or has vague symptoms.
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A patient comes to the emergency department after an argument. The patient is lightheaded, has tingling around the mouth, and complains of difficulty breathing. The patient’s vital signs are: BP 130/70 mm Hg, HR 110 beats/min, RR 32 breaths/min, T 97° F (36.1° C). A nurse should FIRST
Detailed Rationale
The clinical picture (post-argument, lightheadedness, perioral tingling, tachypnea, normal BP/O2 sat) is classic for hyperventilation syndrome, often triggered by anxiety. The FIRST and most therapeutic intervention is to provide calm reassurance and coach the patient to slow their breathing. Breathing into a paper bag is an outdated and potentially dangerous intervention as it can cause hypoxia, especially if the diagnosis is incorrect (e.g., asthma, PE). ABGs may be obtained later to confirm respiratory alkalosis but are not the first action. Medication (e.g., anxiolytics) might be considered later if reassurance is ineffective.
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Which of the following signs and symptoms would a patient with labyrinthitis MOST likely exhibit?
Detailed Rationale
Labyrinthitis is an inflammation of the inner ear (labyrinth), typically viral, that disrupts vestibular function. The hallmark symptoms are acute, severe vertigo (a spinning sensation) and nystagmus (involuntary eye movements). Nausea and vomiting are common associated symptoms due to the vertigo. Purulent drainage indicates otitis externa or media, not isolated labyrinthitis. Severe headache is not a primary feature.
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Triage of a 70-year-old man who has an acute onset of a severe headache will be MOST affected by which of the following factors?
Detailed Rationale
In triage, the goal is to identify life-threatening conditions. An acute severe headache in an older adult raises concern for an intracranial hemorrhage (e.g., subdural, intracerebral). Current use of warfarin, an anticoagulant, significantly increases the risk and severity of such bleeds. This factor would immediately elevate the patient's triage acuity. Photophobia is associated with migraines or meningitis but is not as high-risk an indicator as anticoagulation. Depression and digoxin use are less directly related to acute headache emergencies.
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A patient involved in a high-speed motor vehicle crash has an initial blood pressure of 165/89 mm Hg and a heart rate of 110 beats/min. Reassessment reveals the patient is now cool and clammy with an altered mental status and jugular vein distention. The blood pressure has dropped to 80/40 mm Hg and the heart rate is 122 beats/min. The MOST likely reason for this change is
Detailed Rationale
This presentation describes Beck's triad (hypotension, JVD, muffled heart sounds - though not listed) and pulsus paradoxus, which is classic for pericardial tamponade. In tamponade, fluid in the pericardial sac compresses the heart, impairing filling and causing a precipitous drop in cardiac output. The initial normal BP may represent a 'lucid interval' or compensated state. The combination of hypotension, JVD (indicative of elevated central venous pressure), and tachycardia in a trauma patient is highly suggestive. Transtentorial herniation causes neurological changes and Cushing's triad (hypertension, bradycardia, irregular respirations). Diaphragmatic rupture and flail chest primarily cause respiratory distress.
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A crying 4-year-old boy presents with significant foreskin edema. A nurse should prepare the child for
Detailed Rationale
This describes paraphimosis, a urologic emergency where the retracted foreskin cannot be returned to its normal position, causing constriction and edema of the glans. The priority intervention is manual reduction, which involves gentle compression of the edematous glans and foreskin and then pulling the foreskin forward. Looking for a constricting hair or thread (a 'hair tourniquet') is part of the assessment, especially in infants. If manual reduction fails, emergency dorsal slit procedure may be needed. Imaging and lab work are not first-line for this clear clinical diagnosis.
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The individual MOST likely to commit suicide is the one who
Detailed Rationale
While all factors are associated with suicide risk, the presence of a specific, lethal plan is one of the strongest predictors of imminent suicide. It moves beyond ideation or general risk factors to concrete intent and means. The other options describe common risk factors or correlates, but a detailed plan with high lethality indicates a higher level of immediate danger.
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A patient involved in an assault sustains a karate-type blow to the neck. Hoarseness and dyspnea are noted. A nurse should suspect
Detailed Rationale
A direct blunt blow to the anterior neck (a 'clothesline' or karate chop injury) can fracture the laryngeal cartilage (thyroid or cricoid). Signs of laryngeal fracture include hoarseness/voice change, dyspnea/stridor, subcutaneous emphysema (crepitus), and tenderness over the larynx. This is an airway emergency. Vocal cord paralysis is more gradual or post-surgical. Tracheal stenosis is a chronic condition. Trauma to the distal bronchus is associated with major chest trauma, not an isolated neck blow.
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Which of the following is MOST consistent with an abusive situation?
Detailed Rationale
In suspected abuse, certain patterns are red flags. For a toddler, bruises on bilateral lower legs in varying stages of healing are highly suspicious for non-accidental trauma (e.g., repeated grabbing, shaking). Toddlers do get bruises on their shins from falls, but bilateral, multiple-stage bruises are concerning. A teenager with a mandible fracture from a fight may or may not be abuse. An elderly patient reporting financial/medication withholding is a sign of potential elder abuse. A fall in a nursing home could be accidental or neglectful. The toddler's bruising pattern is the most classic physical finding of abuse among the options.
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A patient who has received facial sutures should be instructed to have the sutures removed in how many days?
Detailed Rationale
Facial skin has an excellent blood supply and heals quickly. To minimize scarring, sutures on the face are typically removed in 3 to 5 days. Leaving them in longer increases the risk of suture marks ('track marks'). Sutures on other body parts (e.g., extremities, trunk) are left in longer (7-14 days) due to slower healing and higher tension.
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A patient with anorexia nervosa presents complaining of muscle weakness and cramps. A nurse should anticipate the need for
Detailed Rationale
Patients with severe anorexia nervosa are at extreme risk for electrolyte imbalances due to malnutrition and purging behaviors. Hypokalemia, hypophosphatemia, and hypomagnesemia are common and can cause muscle weakness, cramps, and, most critically, life-threatening cardiac arrhythmias (e.g., prolonged QT interval, torsades de pointes). Therefore, cardiac monitoring is essential. Fluids may be needed but must be given cautiously (risk of refeeding syndrome). Muscle relaxants and NSAIDs do not address the underlying electrolyte disturbance.
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