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An assault victim is hypotensive with palpable left rib tenderness and has not responded to IV fluids. A nurse should prepare for IMMEDIATE
Detailed Rationale
The Focused Assessment with Sonography for Trauma (FAST) exam is a rapid, bedside ultrasound used to detect free fluid (blood) in the pericardial, peritoneal, or pleural spaces. In an unstable trauma patient with potential intra-abdominal injury (left rib fractures can injure the spleen), the FAST exam is the quickest way to identify life-threatening hemorrhage requiring immediate surgery.
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A patient who has a ruptured Achilles tendon MOST likely would experience
Detailed Rationale
A ruptured Achilles tendon classically presents with a sudden, sharp, or popping sensation in the back of the ankle/calf, often described as feeling like being kicked, followed by severe pain, swelling, and inability to plantarflex the foot. Neurovascular compromise is rare.
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A urinary catheter is inserted in a patient who has third-degree burns over 60% of the body. The initial output is slightly cloudy, but then becomes progressively deeper red to almost black. The patient may have renal damage secondary to
Detailed Rationale
Massive deep burns cause muscle damage (rhabdomyolysis), releasing myoglobin into the bloodstream. Myoglobin is nephrotoxic and can cause acute renal failure. It gives urine a characteristic dark red to cola-colored appearance. This is a common and serious complication of major burns.
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A patient is alert, dyspneic, and has pain on the left side after a motor vehicle crash. The chest radiograph reveals a diaphragmatic rupture with herniation of the stomach into the thoracic cavity. A nasogastric tube is inserted, and 300 mL of dark-colored stomach secretions is returned. A nurse should
Detailed Rationale
The NG tube decompresses the herniated stomach, relieving pressure on the lungs and improving ventilation. Continuous suction is maintained to keep the stomach empty and prevent further respiratory compromise. The dark color is normal for gastric secretions (bile-stained).
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A patient who is 33 weeks pregnant presents with painless, bright red vaginal bleeding. The patient is gravida 3, para 2 and reports two previous cesarean sections. The PRIORITY intervention is to
Detailed Rationale
This presentation is highly suspicious for placenta previa (painless third-trimester bleeding). A history of prior C-sections is a risk factor. A digital pelvic exam is CONTRAINDICATED as it can cause catastrophic hemorrhage. The immediate priority is to assess fetal well-being via heart tones. Ultrasound is diagnostic, but fetal assessment comes first.
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A patient presents with symptoms of alcohol withdrawal. The nurse should prepare to administer
Detailed Rationale
Benzodiazepines (like lorazepam) are the first-line treatment for alcohol withdrawal. They are cross-tolerant with alcohol, help prevent seizures, reduce autonomic hyperactivity (tremors, tachycardia), and treat agitation. Naloxone is for opioid overdose. Antipsychotics like chlorpromazine lower seizure threshold.
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Acute renal failure in a patient who sustains a crushing injury is MOST likely due to
Detailed Rationale
Crush injuries cause rhabdomyolysis (muscle breakdown), releasing myoglobin into the bloodstream. Myoglobin is directly toxic to renal tubules, especially in the setting of dehydration and acidosis, leading to acute renal failure. This is a well-known complication of major trauma.
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A patient presents with a sore throat and a temperature of 104°F (40°C). The tonsils are grossly swollen and covered with a white, patchy exudate. These symptoms are MOST consistent with
Detailed Rationale
While both strep throat and mono can cause exudative tonsillitis, the high fever is more classic for acute bacterial pharyngitis (Strep pyogenes). Mononucleosis often has more systemic symptoms like fatigue and lymphadenopathy. Peritonsillar abscess is usually unilateral with deviation of the uvula. Epiglottitis presents with drooling and respiratory distress.
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A 6-year-old child with a history of hydrocephalus has a shunt malfunction. Which of the following interventions is MOST important in planning this child's care?
Detailed Rationale
Elevating the head of the bed promotes venous drainage from the brain, which can help reduce intracranial pressure (ICP) while awaiting definitive management (e.g., shunt revision). This is a standard, immediate nursing intervention for suspected increased ICP.
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A patient presents with lethargy, chills, fever, lower back pain, and dysuria. The patient is MOST likely exhibiting signs of
Detailed Rationale
Pyelonephritis is an upper urinary tract infection (kidney infection). It presents with systemic signs of infection (fever, chills, lethargy) along with flank/back pain and urinary symptoms (dysuria). A simple lower UTI (cystitis) typically lacks the systemic symptoms and flank pain.
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Which of the following characteristics indicates the late phase of septic shock?
Detailed Rationale
In the late (decompensated) phase of septic shock, the patient progresses from a hyperdynamic state (warm, flushed, bounding pulses) to a hypodynamic state due to myocardial depression and worsening vasodilation. This results in weak, thready pulses, cool/clammy skin, and profound hypotension.
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The nurse is resuscitating a patient with heat stroke. Which of the following regarding treatment is correct?
Detailed Rationale
The cornerstone of heat stroke treatment is rapid, active external cooling (e.g., ice packs, cooling blankets, evaporative cooling) to reduce core temperature as quickly as possible. This is the single most important intervention to decrease morbidity and mortality. Antipyretics are ineffective. Fluids are given cautiously.
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A patient is being transferred to another hospital. The legal responsibility of the referring hospital terminates at the time
Detailed Rationale
Under EMTALA, the legal responsibility of the transferring hospital continues until the patient is physically received and care is assumed by the receiving hospital. The handoff is not complete until the patient arrives and is accepted into the new facility's care.
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A patient presents with profuse, painless, vaginal bleeding. Which of the following assessment findings indicates the need for immediate intervention?
Detailed Rationale
Positive orthostatic vital signs (a drop in BP or rise in HR upon standing) indicate significant volume depletion (at least 15-20% blood loss). In the context of profuse bleeding, this signals hypovolemic shock and requires immediate fluid resuscitation and intervention to control the bleeding.
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A 62-year-old woman is brought to the emergency department following a syncopal episode. The patient reports weakness, fatigue, back pain, and shortness of breath. Crackles (rales) are noted on auscultation, and her skin is pale, cool, and clammy. Vital signs are as follows: BP: 87/50 mm Hg; HR: 132 beats/min; RR: 32 breaths/min; Temperature: 98.7°F (37.1°C). A nurse should suspect
Detailed Rationale
The patient presents with signs of pump failure: hypotension, tachycardia, pulmonary edema (crackles), poor perfusion (cool/clammy skin), and possible cardiac chest/back pain. This constellation points to cardiogenic shock, where the heart cannot pump sufficiently to meet the body's demands.
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A 4-year-old child has a sore throat, fever, and a thick, gray membrane on the tonsils. A nurse should suspect
Detailed Rationale
Diphtheria, caused by Corynebacterium diphtheriae, classically presents with a sore throat, fever, and a grayish pseudomembrane that adheres to the tonsils/pharynx. It is a serious, vaccine-preventable disease. Mumps causes parotid swelling. Rubella and measles cause rash.
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A child has been diagnosed with pertussis. Which of the following medications should the nurse expect to administer?
Detailed Rationale
Pertussis (whooping cough) is caused by the bacterium Bordetella pertussis. The primary treatment is antibiotics, specifically macrolides like azithromycin, which can reduce transmission and may lessen severity if given early. While supportive care (including oxygen, hydration, and sometimes bronchodilators) is important, antibiotics are the definitive pharmacological treatment. Corticosteroids and decongestants are not standard treatments for pertussis.
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A patient with a flail chest and pneumothorax has been intubated and a chest tube was inserted. The patient quickly develops subcutaneous air in his arms, neck, and face. This presentation is consistent with
Detailed Rationale
Subcutaneous emphysema (air under the skin) that rapidly spreads to the neck, face, and arms indicates that air has tracked into the mediastinum (pneumomediastinum) and then into subcutaneous tissues. This can occur due to alveolar rupture from high pressures (e.g., with flail chest/ventilation) or from an airway injury. While a tracheobronchial injury can cause pneumomediastinum, the described spread is classic for subcutaneous emphysema from pneumomediastinum. Tension pneumothorax causes unilateral findings and hemodynamic compromise. Ruptured diaphragm causes abdominal contents in the chest.
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Which of the following serum electrolyte levels is elevated in acidosis?
Detailed Rationale
In acidosis (especially metabolic acidosis), hydrogen ions (H+) move into cells in exchange for potassium ions (K+), leading to hyperkalemia (elevated serum K+). This is a critical electrolyte disturbance to recognize. Calcium, magnesium, and sodium levels are not directly elevated in this consistent manner by acidosis.
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A patient with an automated implantable cardioverter-defibrillator (AICD/ICD) suddenly becomes unresponsive and pulseless. The cardiac monitor shows ventricular tachycardia. Which of the following should the nurse do FIRST?
Detailed Rationale
In a pulseless patient with ventricular tachycardia (VT), this is cardiac arrest (pulseless VT). The AICD is designed to treat hemodynamically stable VT. In cardiac arrest, Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) protocols take precedence. The FIRST action for pulseless VT is immediate defibrillation. Do not wait for the AICD to fire. Start CPR if a defibrillator is not immediately available. Synchronized cardioversion is for unstable patients with a pulse.
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A 3-year-old child is diagnosed with meningitis. An increase in which of the following would be MOST indicative of a worsening condition?
Detailed Rationale
In meningitis, a spreading purpuric or petechial rash, especially one that is rapid and extensive, is a hallmark of worsening septicemia, often associated with meningococcal disease. This is a medical emergency indicating possible progression to septic shock and DIC. While irritability, fever, and an elevated WBC are concerning, the expansion of a hemorrhagic rash is a more specific and visual sign of deteriorating systemic infection.
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A patient who has a history of migraines comes to the emergency department with a severe headache. Which of the following statements by the patient would be of greatest concern to a nurse?
Detailed Rationale
In a patient with a history of migraines, a headache that is qualitatively different ('the worst headache of my life' or 'never had one like this before') is a major red flag for a more serious cause, such as subarachnoid hemorrhage, meningitis, or tumor. Visual auras (flashing lights) and vomiting are common in migraines. Irritability can also occur. The change in pattern is the critical finding.
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Which of the following symptoms may be exhibited by a patient with diabetes mellitus with a blood glucose level of 40 mg/dL?
Detailed Rationale
A blood glucose of 40 mg/dL indicates severe hypoglycemia. Neuroglycopenic symptoms include slurred speech, confusion, seizures, and loss of consciousness. Kussmaul respirations (deep, rapid breathing) and acetone breath are signs of diabetic ketoacidosis (hyperglycemia). Bradycardia is not typical; tachycardia and diaphoresis are more common autonomic symptoms of hypoglycemia.
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A coworker has had increased call-outs, withdrawal, and verbal outbursts. The nurse should recognize that the coworker may be experiencing
Detailed Rationale
Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment often caused by chronic workplace stress. The symptoms described (absenteeism, social withdrawal, irritability/outbursts) are classic indicators of job burnout. While depression and anxiety can co-exist, the pattern is specifically aligned with occupational burnout. Denial is a defense mechanism, not a syndrome.
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A patient presents to the emergency department complaining of a gradual onset of sharp scrotal pain associated with erythema and swelling. The patient rates his pain as 6 out of 10 and states the pain is made worse with heavy lifting. The nurse notes a 'duck waddle' gait and slight fever. A nurse should suspect
Detailed Rationale
Epididymitis typically presents with gradual onset of scrotal pain, swelling, erythema, and fever. The pain may be relieved by scrotal elevation (Prehn's sign) and is often exacerbated by physical activity. The 'duck waddle' gait is an attempt to minimize friction and pain. Testicular torsion is sudden, severe, and requires immediate surgery; it often lacks fever. A hernia causes a bulge, not primarily scrotal swelling. Urinary calculus pain radiates to the groin but doesn't cause significant scrotal swelling/erythema.
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Which of the following statements about initial reactions to an amitriptyline (Elavil) overdose is true?
Detailed Rationale
Tricyclic antidepressant (like amitriptyline) overdose can be unpredictable. Patients may appear asymptomatic initially but are at risk for sudden deterioration, including QRS widening, arrhythmias (e.g., ventricular tachycardia), and seizures, due to the drug's delayed absorption and cardiotoxic effects. Continuous cardiac monitoring is essential regardless of initial presentation. Anticholinergic effects (dry mouth, dilated pupils) are common but not predictive of severity. Asymptomatic patients can still have ingested a toxic dose.
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Which of the following conditions is associated with cardiac arrest secondary to ventricular fibrillation?
Detailed Rationale
Hyperkalemia (elevated potassium) is a common and reversible cause of ventricular fibrillation (VF) and cardiac arrest. High serum potassium levels destabilize cardiac cell membranes, leading to arrhythmias, peaked T waves, widening QRS, and ultimately VF. Aortic stenosis, tamponade, and hypovolemia more commonly lead to pulseless electrical activity (PEA) or asystole.
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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
Tuberculosis is spread via airborne droplets. Close, prolonged contact in congregate settings like nursing homes, homeless shelters, or correctional facilities significantly increases the risk of exposure and transmission. Smoking is a risk factor for many lung diseases but not a primary risk factor for TB acquisition. Recurrent pneumonia and antibiotic use are not specific TB risk factors.
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A patient presents with a sore throat that is markedly more painful on the right side. The patient has a temperature of 101.8° F (38.7° C). Which of the following is the MOST concerning finding?
Detailed Rationale
Inability to tolerate one's own secretions (drooling, pooling of saliva) is a classic sign of a potential airway emergency, such as in epiglottitis, peritonsillar abscess, or deep neck space infection. It indicates significant swelling and/or pain impairing swallowing. This requires immediate evaluation. Lateral positioning preference may indicate a unilateral abscess. A history of rash suggests scarlet fever (strep), which is less acute. Fever duration is less specific.
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Which of the following is the IMMEDIATE effect of hyperventilation in a patient?
Detailed Rationale
Hyperventilation is defined as an increase in respiratory rate and/or tidal volume leading to excessive exhalation of carbon dioxide (CO2). The immediate effect is a drop in arterial partial pressure of CO2 (PaCO2), which causes respiratory alkalosis. Hypercarbia (increased CO2) is the opposite. Hypoxia is not an immediate effect of hyperventilation (it may cause lightheadedness from vasoconstriction). Lactic acidosis is metabolic.
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A patient receiving naloxone (Narcan) for a narcotic overdose should be evaluated for
Detailed Rationale
Naloxone has a shorter half-life (30-90 minutes) than many opioids (e.g., methadone, extended-release formulations). Therefore, patients can re-narcotize (slip back into respiratory depression) as the naloxone wears off. Continuous monitoring for the return of sedation, respiratory depression, and other narcotic effects is essential, and repeat doses may be needed. Nystagmus, rash, and orthostasis are not typical concerns.
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A patient who had an ischemic stroke presents with a blood pressure of 148/98 mm Hg and is stable, alert and oriented. The patient was known to be well 14 hours ago. The nurse should recognize that the patient may be a candidate for
Detailed Rationale
(This is a repeat of question #8 from the first set). The key factor is the 14-hour timeline, outside the 4.5-hour window for IV tPA. However, for patients with a large vessel occlusion, endovascular intervention (mechanical thrombectomy) may be an option up to 24 hours based on advanced imaging. The BP is not severely elevated, so aggressive antihypertensives are not indicated. Anticonvulsants are not standard.
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A patient has a heart rate of 40 beats/min and a palpable blood pressure of 80 mm Hg. A transcutaneous pacemaker is applied, and a nurse sees the following rhythm on the monitor: A. improper pad placement B. failure to capture C. failure to pace D. failure to sense
Detailed Rationale
The ECG rhythm shows pacemaker spikes that are not consistently followed by a QRS complex, indicating that although the transcutaneous pacemaker is delivering electrical impulses, the myocardium is not responding to them. This situation is defined as failure to capture and is commonly caused by insufficient pacing current. In contrast, failure to pace would show no pacer spikes at all, and failure to sense would show pacer spikes occurring inappropriately within intrinsic cardiac activity. Therefore, the nurse should recognize this rhythm as failure to capture and anticipate increasing the pacing milliamperes until electrical and mechanical capture are achieved.
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A patient has a fractured femur and a cool, cyanotic foot. Which of the following provides the BEST indication that successful immobilization has been achieved?
Detailed Rationale
A cool, cyanotic foot distal to a femur fracture indicates vascular compromise, likely from the bone ends kinking or compressing the femoral artery. The primary goal of immobilization (e.g., with traction splint) is to realign the bone ends, relieving pressure on the neurovascular structures. The return of adequate perfusion, evidenced by capillary refill <2 seconds, is the best direct indicator that immobilization has successfully restored blood flow. A palpable femoral pulse is proximal and may not reflect distal perfusion. Decreased sensation is a neurological sign, and decreased deformity is a mechanical goal, but perfusion status is the most critical indicator of success in this scenario.
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A patient who had an ischemic stroke presents with a blood pressure of 148/98 mm Hg and is stable, alert and oriented. The patient was known to be well 14 hours ago. The nurse should recognize that the patient may be a candidate for
Detailed Rationale
The key factor is the 14-hour timeline. The standard window for intravenous fibrinolytic therapy (like tPA) is within 4.5 hours of symptom onset. This patient is well outside that window. However, for patients with a large vessel occlusion presenting within 6-24 hours, endovascular intervention (mechanical thrombectomy) may still be an option based on advanced imaging (CT perfusion, MRI). The blood pressure is moderately elevated but is often not treated aggressively acutely unless extremely high, as it may be needed to perfuse the ischemic penumbra. Anticonvulsants are not a standard initial stroke treatment.
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A patient presents with dysphagia, bilateral submandibular swelling, and elevation and protrusion of the tongue 24 hours after a wisdom tooth extraction. The nurse should suspect:
Detailed Rationale
Ludwig's angina is a rapidly spreading, potentially life-threatening cellulitis of the submandibular and sublingual spaces, often originating from a dental infection (e.g., wisdom tooth). The classic signs are bilateral submandibular swelling, elevation and protrusion of the tongue (often described as 'woody' induration), dysphagia, and potential airway compromise. Peritonsillar abscess is typically unilateral. Acute thyroiditis involves the thyroid gland, not the submandibular space. Strep pharyngitis does not cause this degree of swelling or tongue elevation.
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A patient has edematous feet with decreased hair growth, brown patches of skin, mottled rubor, and flaking skin on the lower extremities. Legs are warm, with palpable pulses, and capillary refill is less than 3 seconds. The nurse should ask about a history of:
Detailed Rationale
These are classic signs of chronic venous insufficiency (CVI). Venous hypertension leads to edema, stasis dermatitis (brown hemosiderin deposits from RBC breakdown), and skin changes like dryness/flaking. The legs are warm with good pulses because the arterial supply is intact, which rules out peripheral arterial disease (PAD) as the primary cause. PAD presents with cool, pale, hairless limbs with diminished pulses and pain. Diabetes and vasculitis can contribute but are not the most direct cause of this specific presentation.
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Assessment of a patient being treated for a dissecting aortic aneurysm reveals the following: BP 170/100 mm Hg, HR 90 beats/min, RR 24 breaths/min. The FIRST intervention that a nurse should anticipate is administering
Detailed Rationale
The primary goals in managing an aortic dissection are to reduce shear stress on the aortic wall by lowering the systolic blood pressure and decreasing the force of ventricular contraction (dP/dt). Nitroprusside is a potent, titratable intravenous vasodilator that is a first-line agent for rapid blood pressure control in this emergency. It is almost always used in conjunction with a beta-blocker (like esmolol) to control heart rate and contractility. Nitroglycerin is more for coronary ischemia and preload reduction. Diltiazem is a calcium channel blocker that can be used. Enalapril is an ACE inhibitor not used for acute management.
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A detached retina should be suspected if which of the following clinical signs suddenly develops?
Detailed Rationale
A sudden increase in floaters (dark spots or strands), flashes of light (photopsia), and a curtain or shadow over the visual field are the classic symptoms of retinal detachment. Photophobia is more common with iritis or corneal injury. Severe pain is typical of acute angle-closure glaucoma or corneal abrasion. Unequal pupils (anisocoria) can be normal or indicate other neurological issues but are not specific to retinal detachment.
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An early indication of an increase in intracranial pressure is demonstrated by
Detailed Rationale
The earliest and most sensitive sign of increasing intracranial pressure (ICP) is a change in mental status, such as confusion, restlessness, lethargy, or a decreased level of consciousness. This occurs because the rising pressure impairs cerebral blood flow and brain function. Flexion/extension posturing (decorticate/decerebrate) are late signs of severe brainstem herniation. Cushing's triad (bradycardia, hypertension, irregular respirations) and fixed, dilated pupils are also late, ominous signs indicating imminent herniation.
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A patient with an aortic dissection is being treated with a continuous infusion of esmolol (Brevibloc). The nurse determines the patient's treatment is effective when the patient's systolic blood pressure is
Detailed Rationale
The goal in medical management of aortic dissection is to reduce shear stress on the aortic wall. This is achieved by lowering systolic blood pressure (typically to 100-120 mm Hg) and heart rate (to ~60 bpm). A systolic BP of 70 mm Hg would likely cause hypoperfusion. Systolic BPs of 160 or 180 mm Hg are too high and would perpetuate the dissection. A target around 100 mm Hg is standard, balancing the need to reduce wall stress with maintaining adequate organ perfusion.
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A 10-month-old infant is diagnosed with an intracranial bleed. Which of the following findings should alert a nurse to suspect child maltreatment?
Detailed Rationale
While all can be present in an injured infant, retinal hemorrhages in the context of an intracranial bleed (especially subdural hematoma) are a hallmark of abusive head trauma (shaken baby syndrome). They are caused by violent acceleration-deceleration forces and are rarely seen in accidental trauma. A sudden onset of lethargy and inconsolability are concerning but non-specific. Bruising on the forehead is common in toddlers learning to walk from accidental falls.
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A patient presents to the emergency department from a house fire. Which of the following findings would be MOST concerning?
Detailed Rationale
In burn/inhalation injury patients, airway compromise is the immediate life threat. Hoarseness, stridor, soot in the nares/oropharynx, and singed facial hair indicate upper airway thermal injury or significant smoke inhalation. Swelling can progress rapidly and lead to complete airway obstruction. A hoarse voice is a direct sign of laryngeal edema. While the other findings (alcohol, blister, fracture) require assessment and treatment, they do not represent the same level of imminent, lethal danger as a compromised airway.
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A 6-week-old infant is brought to the emergency department with lethargy, poor appetite, and a temperature of 102°F (38.8°C) for the past 24 hours. A nurse should prepare to
Detailed Rationale
A febrile infant under 2-3 months of age is considered a 'septic workup' candidate because they are at high risk for serious bacterial infections (meningitis, UTI, bacteremia) due to an immature immune system. The standard workup includes blood cultures, urine studies, and often a lumbar puncture (LP) to rule out meningitis. Antipyretics (not tepid sponging first-line) are given. Anticonvulsants are not prophylactic. Isolation is not indicated without a specific contagious diagnosis.
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An assault victim is hypotensive with palpable left rib tenderness and has not responded to IV fluids. A nurse should prepare for IMMEDIATE
Detailed Rationale
The Focused Assessment with Sonography for Trauma (FAST) exam is a rapid, bedside ultrasound used to detect free fluid (blood) in the pericardial, peritoneal, or pleural spaces. In an unstable trauma patient with potential intra-abdominal injury (left rib fractures can injure the spleen), the FAST exam is the quickest way to identify life-threatening hemorrhage requiring immediate surgery.
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A patient who has a ruptured Achilles tendon MOST likely would experience
Detailed Rationale
A ruptured Achilles tendon classically presents with a sudden, sharp, or popping sensation in the back of the ankle/calf, often described as feeling like being kicked, followed by severe pain, swelling, and inability to plantarflex the foot. Neurovascular compromise is rare.
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A urinary catheter is inserted in a patient who has third-degree burns over 60% of the body. The initial output is slightly cloudy, but then becomes progressively deeper red to almost black. The patient may have renal damage secondary to
Detailed Rationale
Massive deep burns cause muscle damage (rhabdomyolysis), releasing myoglobin into the bloodstream. Myoglobin is nephrotoxic and can cause acute renal failure. It gives urine a characteristic dark red to cola-colored appearance. This is a common and serious complication of major burns.
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A patient is alert, dyspneic, and has pain on the left side after a motor vehicle crash. The chest radiograph reveals a diaphragmatic rupture with herniation of the stomach into the thoracic cavity. A nasogastric tube is inserted, and 300 mL of dark-colored stomach secretions is returned. A nurse should
Detailed Rationale
The NG tube decompresses the herniated stomach, relieving pressure on the lungs and improving ventilation. Continuous suction is maintained to keep the stomach empty and prevent further respiratory compromise. The dark color is normal for gastric secretions (bile-stained).
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A patient who is 33 weeks pregnant presents with painless, bright red vaginal bleeding. The patient is gravida 3, para 2 and reports two previous cesarean sections. The PRIORITY intervention is to
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This presentation is highly suspicious for placenta previa (painless third-trimester bleeding). A history of prior C-sections is a risk factor. A digital pelvic exam is CONTRAINDICATED as it can cause catastrophic hemorrhage. The immediate priority is to assess fetal well-being via heart tones. Ultrasound is diagnostic, but fetal assessment comes first.
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A patient presents with symptoms of alcohol withdrawal. The nurse should prepare to administer
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Benzodiazepines (like lorazepam) are the first-line treatment for alcohol withdrawal. They are cross-tolerant with alcohol, help prevent seizures, reduce autonomic hyperactivity (tremors, tachycardia), and treat agitation. Naloxone is for opioid overdose. Antipsychotics like chlorpromazine lower seizure threshold.
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Acute renal failure in a patient who sustains a crushing injury is MOST likely due to
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Crush injuries cause rhabdomyolysis (muscle breakdown), releasing myoglobin into the bloodstream. Myoglobin is directly toxic to renal tubules, especially in the setting of dehydration and acidosis, leading to acute renal failure. This is a well-known complication of major trauma.
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A patient presents with a sore throat and a temperature of 104°F (40°C). The tonsils are grossly swollen and covered with a white, patchy exudate. These symptoms are MOST consistent with
Detailed Rationale
While both strep throat and mono can cause exudative tonsillitis, the high fever is more classic for acute bacterial pharyngitis (Strep pyogenes). Mononucleosis often has more systemic symptoms like fatigue and lymphadenopathy. Peritonsillar abscess is usually unilateral with deviation of the uvula. Epiglottitis presents with drooling and respiratory distress.
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A 6-year-old child with a history of hydrocephalus has a shunt malfunction. Which of the following interventions is MOST important in planning this child's care?
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Elevating the head of the bed promotes venous drainage from the brain, which can help reduce intracranial pressure (ICP) while awaiting definitive management (e.g., shunt revision). This is a standard, immediate nursing intervention for suspected increased ICP.
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A patient presents with lethargy, chills, fever, lower back pain, and dysuria. The patient is MOST likely exhibiting signs of
Detailed Rationale
Pyelonephritis is an upper urinary tract infection (kidney infection). It presents with systemic signs of infection (fever, chills, lethargy) along with flank/back pain and urinary symptoms (dysuria). A simple lower UTI (cystitis) typically lacks the systemic symptoms and flank pain.
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Which of the following characteristics indicates the late phase of septic shock?
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In the late (decompensated) phase of septic shock, the patient progresses from a hyperdynamic state (warm, flushed, bounding pulses) to a hypodynamic state due to myocardial depression and worsening vasodilation. This results in weak, thready pulses, cool/clammy skin, and profound hypotension.
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The nurse is resuscitating a patient with heat stroke. Which of the following regarding treatment is correct?
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The cornerstone of heat stroke treatment is rapid, active external cooling (e.g., ice packs, cooling blankets, evaporative cooling) to reduce core temperature as quickly as possible. This is the single most important intervention to decrease morbidity and mortality. Antipyretics are ineffective. Fluids are given cautiously.
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A patient is being transferred to another hospital. The legal responsibility of the referring hospital terminates at the time
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Under EMTALA, the legal responsibility of the transferring hospital continues until the patient is physically received and care is assumed by the receiving hospital. The handoff is not complete until the patient arrives and is accepted into the new facility's care.
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A patient presents with profuse, painless, vaginal bleeding. Which of the following assessment findings indicates the need for immediate intervention?
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Positive orthostatic vital signs (a drop in BP or rise in HR upon standing) indicate significant volume depletion (at least 15-20% blood loss). In the context of profuse bleeding, this signals hypovolemic shock and requires immediate fluid resuscitation and intervention to control the bleeding.
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A 62-year-old woman is brought to the emergency department following a syncopal episode. The patient reports weakness, fatigue, back pain, and shortness of breath. Crackles (rales) are noted on auscultation, and her skin is pale, cool, and clammy. Vital signs are as follows: BP: 87/50 mm Hg; HR: 132 beats/min; RR: 32 breaths/min; Temperature: 98.7°F (37.1°C). A nurse should suspect
Detailed Rationale
The patient presents with signs of pump failure: hypotension, tachycardia, pulmonary edema (crackles), poor perfusion (cool/clammy skin), and possible cardiac chest/back pain. This constellation points to cardiogenic shock, where the heart cannot pump sufficiently to meet the body's demands.
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A 4-year-old child has a sore throat, fever, and a thick, gray membrane on the tonsils. A nurse should suspect
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Diphtheria, caused by Corynebacterium diphtheriae, classically presents with a sore throat, fever, and a grayish pseudomembrane that adheres to the tonsils/pharynx. It is a serious, vaccine-preventable disease. Mumps causes parotid swelling. Rubella and measles cause rash.
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A child has been diagnosed with pertussis. Which of the following medications should the nurse expect to administer?
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Pertussis (whooping cough) is caused by the bacterium Bordetella pertussis. The primary treatment is antibiotics, specifically macrolides like azithromycin, which can reduce transmission and may lessen severity if given early. While supportive care (including oxygen, hydration, and sometimes bronchodilators) is important, antibiotics are the definitive pharmacological treatment. Corticosteroids and decongestants are not standard treatments for pertussis.
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A patient with a flail chest and pneumothorax has been intubated and a chest tube was inserted. The patient quickly develops subcutaneous air in his arms, neck, and face. This presentation is consistent with
Detailed Rationale
Subcutaneous emphysema (air under the skin) that rapidly spreads to the neck, face, and arms indicates that air has tracked into the mediastinum (pneumomediastinum) and then into subcutaneous tissues. This can occur due to alveolar rupture from high pressures (e.g., with flail chest/ventilation) or from an airway injury. While a tracheobronchial injury can cause pneumomediastinum, the described spread is classic for subcutaneous emphysema from pneumomediastinum. Tension pneumothorax causes unilateral findings and hemodynamic compromise. Ruptured diaphragm causes abdominal contents in the chest.
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Which of the following serum electrolyte levels is elevated in acidosis?
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In acidosis (especially metabolic acidosis), hydrogen ions (H+) move into cells in exchange for potassium ions (K+), leading to hyperkalemia (elevated serum K+). This is a critical electrolyte disturbance to recognize. Calcium, magnesium, and sodium levels are not directly elevated in this consistent manner by acidosis.
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A patient with an automated implantable cardioverter-defibrillator (AICD/ICD) suddenly becomes unresponsive and pulseless. The cardiac monitor shows ventricular tachycardia. Which of the following should the nurse do FIRST?
Detailed Rationale
In a pulseless patient with ventricular tachycardia (VT), this is cardiac arrest (pulseless VT). The AICD is designed to treat hemodynamically stable VT. In cardiac arrest, Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) protocols take precedence. The FIRST action for pulseless VT is immediate defibrillation. Do not wait for the AICD to fire. Start CPR if a defibrillator is not immediately available. Synchronized cardioversion is for unstable patients with a pulse.
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A 3-year-old child is diagnosed with meningitis. An increase in which of the following would be MOST indicative of a worsening condition?
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In meningitis, a spreading purpuric or petechial rash, especially one that is rapid and extensive, is a hallmark of worsening septicemia, often associated with meningococcal disease. This is a medical emergency indicating possible progression to septic shock and DIC. While irritability, fever, and an elevated WBC are concerning, the expansion of a hemorrhagic rash is a more specific and visual sign of deteriorating systemic infection.
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A patient who has a history of migraines comes to the emergency department with a severe headache. Which of the following statements by the patient would be of greatest concern to a nurse?
Detailed Rationale
In a patient with a history of migraines, a headache that is qualitatively different ('the worst headache of my life' or 'never had one like this before') is a major red flag for a more serious cause, such as subarachnoid hemorrhage, meningitis, or tumor. Visual auras (flashing lights) and vomiting are common in migraines. Irritability can also occur. The change in pattern is the critical finding.
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Which of the following symptoms may be exhibited by a patient with diabetes mellitus with a blood glucose level of 40 mg/dL?
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A blood glucose of 40 mg/dL indicates severe hypoglycemia. Neuroglycopenic symptoms include slurred speech, confusion, seizures, and loss of consciousness. Kussmaul respirations (deep, rapid breathing) and acetone breath are signs of diabetic ketoacidosis (hyperglycemia). Bradycardia is not typical; tachycardia and diaphoresis are more common autonomic symptoms of hypoglycemia.
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A coworker has had increased call-outs, withdrawal, and verbal outbursts. The nurse should recognize that the coworker may be experiencing
Detailed Rationale
Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment often caused by chronic workplace stress. The symptoms described (absenteeism, social withdrawal, irritability/outbursts) are classic indicators of job burnout. While depression and anxiety can co-exist, the pattern is specifically aligned with occupational burnout. Denial is a defense mechanism, not a syndrome.
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A patient presents to the emergency department complaining of a gradual onset of sharp scrotal pain associated with erythema and swelling. The patient rates his pain as 6 out of 10 and states the pain is made worse with heavy lifting. The nurse notes a 'duck waddle' gait and slight fever. A nurse should suspect
Detailed Rationale
Epididymitis typically presents with gradual onset of scrotal pain, swelling, erythema, and fever. The pain may be relieved by scrotal elevation (Prehn's sign) and is often exacerbated by physical activity. The 'duck waddle' gait is an attempt to minimize friction and pain. Testicular torsion is sudden, severe, and requires immediate surgery; it often lacks fever. A hernia causes a bulge, not primarily scrotal swelling. Urinary calculus pain radiates to the groin but doesn't cause significant scrotal swelling/erythema.
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Which of the following statements about initial reactions to an amitriptyline (Elavil) overdose is true?
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Tricyclic antidepressant (like amitriptyline) overdose can be unpredictable. Patients may appear asymptomatic initially but are at risk for sudden deterioration, including QRS widening, arrhythmias (e.g., ventricular tachycardia), and seizures, due to the drug's delayed absorption and cardiotoxic effects. Continuous cardiac monitoring is essential regardless of initial presentation. Anticholinergic effects (dry mouth, dilated pupils) are common but not predictive of severity. Asymptomatic patients can still have ingested a toxic dose.
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Which of the following conditions is associated with cardiac arrest secondary to ventricular fibrillation?
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Hyperkalemia (elevated potassium) is a common and reversible cause of ventricular fibrillation (VF) and cardiac arrest. High serum potassium levels destabilize cardiac cell membranes, leading to arrhythmias, peaked T waves, widening QRS, and ultimately VF. Aortic stenosis, tamponade, and hypovolemia more commonly lead to pulseless electrical activity (PEA) or asystole.
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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
Tuberculosis is spread via airborne droplets. Close, prolonged contact in congregate settings like nursing homes, homeless shelters, or correctional facilities significantly increases the risk of exposure and transmission. Smoking is a risk factor for many lung diseases but not a primary risk factor for TB acquisition. Recurrent pneumonia and antibiotic use are not specific TB risk factors.
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A patient presents with a sore throat that is markedly more painful on the right side. The patient has a temperature of 101.8° F (38.7° C). Which of the following is the MOST concerning finding?
Detailed Rationale
Inability to tolerate one's own secretions (drooling, pooling of saliva) is a classic sign of a potential airway emergency, such as in epiglottitis, peritonsillar abscess, or deep neck space infection. It indicates significant swelling and/or pain impairing swallowing. This requires immediate evaluation. Lateral positioning preference may indicate a unilateral abscess. A history of rash suggests scarlet fever (strep), which is less acute. Fever duration is less specific.
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Which of the following is the IMMEDIATE effect of hyperventilation in a patient?
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Hyperventilation is defined as an increase in respiratory rate and/or tidal volume leading to excessive exhalation of carbon dioxide (CO2). The immediate effect is a drop in arterial partial pressure of CO2 (PaCO2), which causes respiratory alkalosis. Hypercarbia (increased CO2) is the opposite. Hypoxia is not an immediate effect of hyperventilation (it may cause lightheadedness from vasoconstriction). Lactic acidosis is metabolic.
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A patient receiving naloxone (Narcan) for a narcotic overdose should be evaluated for
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Naloxone has a shorter half-life (30-90 minutes) than many opioids (e.g., methadone, extended-release formulations). Therefore, patients can re-narcotize (slip back into respiratory depression) as the naloxone wears off. Continuous monitoring for the return of sedation, respiratory depression, and other narcotic effects is essential, and repeat doses may be needed. Nystagmus, rash, and orthostasis are not typical concerns.
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A patient who had an ischemic stroke presents with a blood pressure of 148/98 mm Hg and is stable, alert and oriented. The patient was known to be well 14 hours ago. The nurse should recognize that the patient may be a candidate for
Detailed Rationale
(This is a repeat of question #8 from the first set). The key factor is the 14-hour timeline, outside the 4.5-hour window for IV tPA. However, for patients with a large vessel occlusion, endovascular intervention (mechanical thrombectomy) may be an option up to 24 hours based on advanced imaging. The BP is not severely elevated, so aggressive antihypertensives are not indicated. Anticonvulsants are not standard.
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A patient has a heart rate of 40 beats/min and a palpable blood pressure of 80 mm Hg. A transcutaneous pacemaker is applied, and a nurse sees the following rhythm on the monitor: A. improper pad placement B. failure to capture C. failure to pace D. failure to sense
Detailed Rationale
The ECG rhythm shows pacemaker spikes that are not consistently followed by a QRS complex, indicating that although the transcutaneous pacemaker is delivering electrical impulses, the myocardium is not responding to them. This situation is defined as failure to capture and is commonly caused by insufficient pacing current. In contrast, failure to pace would show no pacer spikes at all, and failure to sense would show pacer spikes occurring inappropriately within intrinsic cardiac activity. Therefore, the nurse should recognize this rhythm as failure to capture and anticipate increasing the pacing milliamperes until electrical and mechanical capture are achieved.
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A patient has a fractured femur and a cool, cyanotic foot. Which of the following provides the BEST indication that successful immobilization has been achieved?
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A cool, cyanotic foot distal to a femur fracture indicates vascular compromise, likely from the bone ends kinking or compressing the femoral artery. The primary goal of immobilization (e.g., with traction splint) is to realign the bone ends, relieving pressure on the neurovascular structures. The return of adequate perfusion, evidenced by capillary refill <2 seconds, is the best direct indicator that immobilization has successfully restored blood flow. A palpable femoral pulse is proximal and may not reflect distal perfusion. Decreased sensation is a neurological sign, and decreased deformity is a mechanical goal, but perfusion status is the most critical indicator of success in this scenario.
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A patient who had an ischemic stroke presents with a blood pressure of 148/98 mm Hg and is stable, alert and oriented. The patient was known to be well 14 hours ago. The nurse should recognize that the patient may be a candidate for
Detailed Rationale
The key factor is the 14-hour timeline. The standard window for intravenous fibrinolytic therapy (like tPA) is within 4.5 hours of symptom onset. This patient is well outside that window. However, for patients with a large vessel occlusion presenting within 6-24 hours, endovascular intervention (mechanical thrombectomy) may still be an option based on advanced imaging (CT perfusion, MRI). The blood pressure is moderately elevated but is often not treated aggressively acutely unless extremely high, as it may be needed to perfuse the ischemic penumbra. Anticonvulsants are not a standard initial stroke treatment.
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A patient presents with dysphagia, bilateral submandibular swelling, and elevation and protrusion of the tongue 24 hours after a wisdom tooth extraction. The nurse should suspect:
Detailed Rationale
Ludwig's angina is a rapidly spreading, potentially life-threatening cellulitis of the submandibular and sublingual spaces, often originating from a dental infection (e.g., wisdom tooth). The classic signs are bilateral submandibular swelling, elevation and protrusion of the tongue (often described as 'woody' induration), dysphagia, and potential airway compromise. Peritonsillar abscess is typically unilateral. Acute thyroiditis involves the thyroid gland, not the submandibular space. Strep pharyngitis does not cause this degree of swelling or tongue elevation.
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A patient has edematous feet with decreased hair growth, brown patches of skin, mottled rubor, and flaking skin on the lower extremities. Legs are warm, with palpable pulses, and capillary refill is less than 3 seconds. The nurse should ask about a history of:
Detailed Rationale
These are classic signs of chronic venous insufficiency (CVI). Venous hypertension leads to edema, stasis dermatitis (brown hemosiderin deposits from RBC breakdown), and skin changes like dryness/flaking. The legs are warm with good pulses because the arterial supply is intact, which rules out peripheral arterial disease (PAD) as the primary cause. PAD presents with cool, pale, hairless limbs with diminished pulses and pain. Diabetes and vasculitis can contribute but are not the most direct cause of this specific presentation.
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Assessment of a patient being treated for a dissecting aortic aneurysm reveals the following: BP 170/100 mm Hg, HR 90 beats/min, RR 24 breaths/min. The FIRST intervention that a nurse should anticipate is administering
Detailed Rationale
The primary goals in managing an aortic dissection are to reduce shear stress on the aortic wall by lowering the systolic blood pressure and decreasing the force of ventricular contraction (dP/dt). Nitroprusside is a potent, titratable intravenous vasodilator that is a first-line agent for rapid blood pressure control in this emergency. It is almost always used in conjunction with a beta-blocker (like esmolol) to control heart rate and contractility. Nitroglycerin is more for coronary ischemia and preload reduction. Diltiazem is a calcium channel blocker that can be used. Enalapril is an ACE inhibitor not used for acute management.
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A detached retina should be suspected if which of the following clinical signs suddenly develops?
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A sudden increase in floaters (dark spots or strands), flashes of light (photopsia), and a curtain or shadow over the visual field are the classic symptoms of retinal detachment. Photophobia is more common with iritis or corneal injury. Severe pain is typical of acute angle-closure glaucoma or corneal abrasion. Unequal pupils (anisocoria) can be normal or indicate other neurological issues but are not specific to retinal detachment.
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An early indication of an increase in intracranial pressure is demonstrated by
Detailed Rationale
The earliest and most sensitive sign of increasing intracranial pressure (ICP) is a change in mental status, such as confusion, restlessness, lethargy, or a decreased level of consciousness. This occurs because the rising pressure impairs cerebral blood flow and brain function. Flexion/extension posturing (decorticate/decerebrate) are late signs of severe brainstem herniation. Cushing's triad (bradycardia, hypertension, irregular respirations) and fixed, dilated pupils are also late, ominous signs indicating imminent herniation.
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A patient with an aortic dissection is being treated with a continuous infusion of esmolol (Brevibloc). The nurse determines the patient's treatment is effective when the patient's systolic blood pressure is
Detailed Rationale
The goal in medical management of aortic dissection is to reduce shear stress on the aortic wall. This is achieved by lowering systolic blood pressure (typically to 100-120 mm Hg) and heart rate (to ~60 bpm). A systolic BP of 70 mm Hg would likely cause hypoperfusion. Systolic BPs of 160 or 180 mm Hg are too high and would perpetuate the dissection. A target around 100 mm Hg is standard, balancing the need to reduce wall stress with maintaining adequate organ perfusion.
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A 10-month-old infant is diagnosed with an intracranial bleed. Which of the following findings should alert a nurse to suspect child maltreatment?
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While all can be present in an injured infant, retinal hemorrhages in the context of an intracranial bleed (especially subdural hematoma) are a hallmark of abusive head trauma (shaken baby syndrome). They are caused by violent acceleration-deceleration forces and are rarely seen in accidental trauma. A sudden onset of lethargy and inconsolability are concerning but non-specific. Bruising on the forehead is common in toddlers learning to walk from accidental falls.
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A patient presents to the emergency department from a house fire. Which of the following findings would be MOST concerning?
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In burn/inhalation injury patients, airway compromise is the immediate life threat. Hoarseness, stridor, soot in the nares/oropharynx, and singed facial hair indicate upper airway thermal injury or significant smoke inhalation. Swelling can progress rapidly and lead to complete airway obstruction. A hoarse voice is a direct sign of laryngeal edema. While the other findings (alcohol, blister, fracture) require assessment and treatment, they do not represent the same level of imminent, lethal danger as a compromised airway.
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A 6-week-old infant is brought to the emergency department with lethargy, poor appetite, and a temperature of 102°F (38.8°C) for the past 24 hours. A nurse should prepare to
Detailed Rationale
A febrile infant under 2-3 months of age is considered a 'septic workup' candidate because they are at high risk for serious bacterial infections (meningitis, UTI, bacteremia) due to an immature immune system. The standard workup includes blood cultures, urine studies, and often a lumbar puncture (LP) to rule out meningitis. Antipyretics (not tepid sponging first-line) are given. Anticonvulsants are not prophylactic. Isolation is not indicated without a specific contagious diagnosis.
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