iHuman Margaret Wilson, heart failure case study, acute decompensated heart failure, ADHF nur

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1. A 16-year-old male fell approximately 12 feet. That would be considered:

 A. a trauma alert
 B. a significant mechanism of injury
 C. not a significant mechanism of injury
 D. a case with a load 'n' go patient
Answer: C. not a significant mechanism of injury
Rationale: A patient over the age of 8 is considered an adult. A fall of greater
than 20 feet is considered a significant mechanism of injury in adults. For infants
and children, a fall greater than 10 feet is significant .

2. A 48-year-old male complains that his chest feels heavy. He is awake and
talking. His skin is pale, cool, and clammy. Your first step is to:

 A. apply your AED
 B. administer supplemental oxygen
 C. obtain a past medical history

,  D. assist the patient in taking his neighbor's nitroglycerin
Answer: B. administer supplemental oxygen
Rationale: When treating chest pain, the first step is to administer supplemental
oxygen to help alleviate damage to the heart muscle .

3. Which of the following heat emergencies is considered a true emergency?

 A. heat cramps
 B. heat exhaustion
 C. heat infarction
 D. heat stroke
Answer: D. heat stroke
Rationale: Heat strokes are considered a true life-threatening emergency. They
typically occur after a patient has experienced heat cramps and heat exhaustion .

4. A patient is breathing 8 times per minute with shallow respirations. This
condition is best described as:

 A. Tachypnea
 B. Hyperventilation
 C. Bradypnea
 D. Dyspnea
Answer: C. Bradypnea
Rationale: Bradypnea refers to abnormally slow respirations, generally fewer than
12 breaths per minute in an adult .

5. Which oxygen delivery device provides the highest concentration of oxygen?

 A. Nasal cannula
 B. Simple face mask
 C. Nonrebreather mask
 D. Venturi mask
Answer: C. Nonrebreather mask

, Rationale: A nonrebreather mask can deliver up to 90–95% oxygen when the
reservoir bag is adequately inflated .

6. The primary function of alveoli is to:

 A. Filter contaminants
 B. Warm inhaled air
 C. Exchange oxygen and carbon dioxide
 D. Transport oxygen to tissues
Answer: C. Exchange oxygen and carbon dioxide
Rationale: Gas exchange occurs across the alveolar membrane in the lungs .

7. A patient with chest pain, pale skin, and diaphoresis should be positioned:

 A. Supine with legs elevated
 B. Trendelenburg
 C. Sitting upright
 D. Prone
Answer: C. Sitting upright
Rationale: This position, often the "position of comfort," helps reduce the
workload on the heart and can ease breathing for a patient in distress .

8. Which of the following is a classic sign of increased intracranial pressure (ICP)
after a head injury?

 A. Hypoxia
 B. Hypoglycemia
 C. Unequal pupils
 D. Dehydration
Answer: C. Unequal pupils
Rationale: Unequal pupils, or anisocoria, are a classic sign of increased
intracranial pressure .

, 9. A flail chest occurs when:

 A. One rib fractures
 B. The sternum separates
 C. Two or more ribs fracture in two places
 D. Air enters the pleural space
Answer: C. Two or more ribs fracture in two places
Rationale: This creates a free-floating chest segment (flail segment) that moves
paradoxically with breathing .

10. Which organ is most sensitive to a lack of oxygen?

 A. Kidneys
 B. Liver
 C. Heart
 D. Brain
Answer: D. Brain
Rationale: Brain cells begin dying within minutes without oxygen, making the
brain the most sensitive organ to hypoxia .

11. A diabetic patient with an altered mental status and cool, clammy skin is likely
experiencing:

 A. Hyperglycemia
 B. Hypoglycemia
 C. Stroke
 D. Seizure
Answer: B. Hypoglycemia
Rationale: Low blood glucose causes a sympathetic nervous system response,
leading to cool, clammy skin and altered mental status .

12. Oral glucose should be given when the patient: