, ENPC 6TH EDITION
EXAM:
1. A 3-year-old patient presents to the emergency department after experiencing
frequent episodes of emesis and diarrhea over the past 12 hours. The nurse
recognizes that the child is at risk for significant fluid loss and begins assessing for
physiologic responses to decreased circulating volume. Which of the following
assessment findings would indicate that the patient's body is compensating for the
fluid loss?
A. Increased diastolic blood pressure
B. Bounding peripheral pulses
C. Prolonged capillary refill
D. Increased urine output
Correct answer: C. Prolonged capillary refill
Prolonged capillary refill reflects peripheral vasoconstriction as the body attempts to
preserve blood flow to vital organs during reduced circulating volume. The
sympathetic nervous system redirects blood away from peripheral tissues, resulting
in delayed color return. The other findings do not indicate an appropriate
compensatory response to fluid loss.
2. You are preparing to discharge a patient home who has a documented history of
depression. Before discharge, the nurse reviews safety measures and the
importance of continued support because the patient may remain at risk for
worsening symptoms or self-harm. Which of the following should be included in
the discharge teaching to promote the patient's safety after leaving the healthcare
facility?
A. Discussing the importance of stopping all current psychiatric medications
B. Providing the family a list of behavioral health facilities to call for follow-up
,C. Explaining that the family should not call authorities for escalations in the patient's
behavior
D. Ensuring all firearms in the home are locked up with no access available by the
patient.
Correct answer: D. Ensuring all firearms in the home are locked up with no
access available by the patient.
Restricting access to firearms is an important suicide-prevention strategy for a
patient with depression because access to lethal means can increase the risk of a
fatal attempt. The family should maintain a safe environment and continue
appropriate behavioral-health follow-up. Psychiatric medications should not be
stopped abruptly unless specifically directed by the treating provider.
3. A child is brought to the emergency department approximately 1 hour after
sustaining an electrical injury. Although the child appears stable, the nurse
understands that electrical injuries can cause internal tissue damage and
complications that may not be immediately visible externally. The nurse therefore
needs to identify a specimen that can provide visual information about a potential
complication. Which of the following specimen samples would be most useful?
A. Serum
B. Urine
C. Stool
D. Sputum
Correct answer: B. Urine
Urine can provide visual evidence of myoglobinuria, which may occur when electrical
injury causes significant muscle damage and rhabdomyolysis. Myoglobin can give the
urine a dark or tea-colored appearance and may contribute to acute kidney injury.
Serum laboratory testing is also important, but urine provides the requested visual
information.
, 4. A 4-year-old patient is being evaluated for a suspected foreign body in the nose.
The child is awake, alert, and comfortably watching a video on the caregiver's
phone, although the initial blood pressure appears elevated for the child's age. The
nurse reviews the vital signs and recognizes that anxiety, movement, or an
incorrectly sized blood pressure cuff could produce an inaccurate reading. Which
intervention should the nurse perform next?
A. Check the size of the blood pressure cuff
B. Recheck the temperature rectally
C. Recheck the blood pressure on the other arm
D. Place the patient on cardiac and respiratory monitors
Correct answer: A. Check the size of the blood pressure cuff
A blood pressure cuff that is too small can produce a falsely elevated blood pressure
reading. Pediatric patients require an appropriately sized cuff based on arm
circumference to obtain an accurate measurement. Because the child's other vital
signs and clinical appearance are relatively stable, verifying the equipment is the
appropriate next step.
5. A 10-year-old child is playing baseball when a ball strikes the child directly in the
chest. Immediately afterward, the child loses consciousness and is found without a
palpable pulse. The team recognizes that a sudden cardiac arrest following a blunt
chest impact can require immediate defibrillation when an appropriate rhythm is
present. Which of the following is the priority intervention?
A. Utilize AED/defibrillator
B. Prepare for needle decompression
C. Administer intravenous epinephrine
D. Intubate with endotracheal tube
Correct answer: A. Utilize AED/defibrillator
A sudden pulseless collapse immediately after a chest impact may represent
commotio cordis, in which a ventricular dysrhythmia can occur. Rapid application of
EXAM:
1. A 3-year-old patient presents to the emergency department after experiencing
frequent episodes of emesis and diarrhea over the past 12 hours. The nurse
recognizes that the child is at risk for significant fluid loss and begins assessing for
physiologic responses to decreased circulating volume. Which of the following
assessment findings would indicate that the patient's body is compensating for the
fluid loss?
A. Increased diastolic blood pressure
B. Bounding peripheral pulses
C. Prolonged capillary refill
D. Increased urine output
Correct answer: C. Prolonged capillary refill
Prolonged capillary refill reflects peripheral vasoconstriction as the body attempts to
preserve blood flow to vital organs during reduced circulating volume. The
sympathetic nervous system redirects blood away from peripheral tissues, resulting
in delayed color return. The other findings do not indicate an appropriate
compensatory response to fluid loss.
2. You are preparing to discharge a patient home who has a documented history of
depression. Before discharge, the nurse reviews safety measures and the
importance of continued support because the patient may remain at risk for
worsening symptoms or self-harm. Which of the following should be included in
the discharge teaching to promote the patient's safety after leaving the healthcare
facility?
A. Discussing the importance of stopping all current psychiatric medications
B. Providing the family a list of behavioral health facilities to call for follow-up
,C. Explaining that the family should not call authorities for escalations in the patient's
behavior
D. Ensuring all firearms in the home are locked up with no access available by the
patient.
Correct answer: D. Ensuring all firearms in the home are locked up with no
access available by the patient.
Restricting access to firearms is an important suicide-prevention strategy for a
patient with depression because access to lethal means can increase the risk of a
fatal attempt. The family should maintain a safe environment and continue
appropriate behavioral-health follow-up. Psychiatric medications should not be
stopped abruptly unless specifically directed by the treating provider.
3. A child is brought to the emergency department approximately 1 hour after
sustaining an electrical injury. Although the child appears stable, the nurse
understands that electrical injuries can cause internal tissue damage and
complications that may not be immediately visible externally. The nurse therefore
needs to identify a specimen that can provide visual information about a potential
complication. Which of the following specimen samples would be most useful?
A. Serum
B. Urine
C. Stool
D. Sputum
Correct answer: B. Urine
Urine can provide visual evidence of myoglobinuria, which may occur when electrical
injury causes significant muscle damage and rhabdomyolysis. Myoglobin can give the
urine a dark or tea-colored appearance and may contribute to acute kidney injury.
Serum laboratory testing is also important, but urine provides the requested visual
information.
, 4. A 4-year-old patient is being evaluated for a suspected foreign body in the nose.
The child is awake, alert, and comfortably watching a video on the caregiver's
phone, although the initial blood pressure appears elevated for the child's age. The
nurse reviews the vital signs and recognizes that anxiety, movement, or an
incorrectly sized blood pressure cuff could produce an inaccurate reading. Which
intervention should the nurse perform next?
A. Check the size of the blood pressure cuff
B. Recheck the temperature rectally
C. Recheck the blood pressure on the other arm
D. Place the patient on cardiac and respiratory monitors
Correct answer: A. Check the size of the blood pressure cuff
A blood pressure cuff that is too small can produce a falsely elevated blood pressure
reading. Pediatric patients require an appropriately sized cuff based on arm
circumference to obtain an accurate measurement. Because the child's other vital
signs and clinical appearance are relatively stable, verifying the equipment is the
appropriate next step.
5. A 10-year-old child is playing baseball when a ball strikes the child directly in the
chest. Immediately afterward, the child loses consciousness and is found without a
palpable pulse. The team recognizes that a sudden cardiac arrest following a blunt
chest impact can require immediate defibrillation when an appropriate rhythm is
present. Which of the following is the priority intervention?
A. Utilize AED/defibrillator
B. Prepare for needle decompression
C. Administer intravenous epinephrine
D. Intubate with endotracheal tube
Correct answer: A. Utilize AED/defibrillator
A sudden pulseless collapse immediately after a chest impact may represent
commotio cordis, in which a ventricular dysrhythmia can occur. Rapid application of
