ENA TRIAGE COMPREHENSIVE ANSWERS AND
QUESTIONS SET A+
✔✔A pediatric patient with increased work of breathing is likely to display which
assessment finding?
A. Grunting
B. Shallow respirations
C. Decreased breath sounds
D. Unlabored breathing - ✔✔A. Grunting
A pediatric patient with increased work of breathing is likely to display grunting, nasal
flaring, tripod positioning, an increased respiratory rate for his or her age, stridor,
labored breathing, accessory muscle use, and head bobbing. Shallow respirations and
decreased breath sounds are signs of decreased work of breathing. Unlabored
breathing is a normal finding.
✔✔The triage nurse should be aware of which performance improvement measure? -
✔✔The acceptable arrival time to triage time
✔✔When triaging a potential psychiatric patient, which action is the triage nurse's
priority? - ✔✔Assess patient and staff safety.
✔✔When triaging a geriatric patient, the triage nurse should routinely perform which
action?
A. Speak loudly to older adults.
B. Use only closed-ended questions to obtain medical history.
C. Determine if the patient has a plan to hurt others.
D. Evaluate the patient's interactions with his or her family. - ✔✔D. Evaluate the
patient's interactions with his or her family.
Admission to the emergency department gives the triage nurse a chance to evaluate the
patients interactions with his or her family. Emergency medical services may provide
, valuable information about the patients living conditions and ability to manage activities
of daily living. Also, screen for older adult abuse and neglect. Use various open-ended
and closed-ended questions to obtain information, including medical history.
Determining whether the patient has a plan for hurting others is appropriate for an older
adult patient who presents with behavioral health concerns. When speaking to an older
adult patient, block out extraneous noise and speak slowly, facing the patient. You do
not necessarily need to speak loudly.
✔✔Which measure best protects patients, staff and visitors from violence in the
emergency department?
A. Presence of plain-clothed security personnel
B. Unrestricted visitor access
C. Staff training in crisis intervention
D. Closed-circuit cameras in triage that can be activated as needed - ✔✔C. Staff
training in crisis intervention
Emergency department staff members must be able to recognize an escalating situation
and intervene appropriately. Security personnel should be visible and uniformed with a
commanding presence. Emergency departments should have a visitor policy that
identifies visitors with passes or badges to control access into the department.
Surveillance of strategic locations, such as emergency department entrances, waiting
areas, and triage rooms, should occur continuously rather than as needed.
✔✔What is the safest way to obtain information from a patient who does not speak
English or is more comfortable speaking in his or her native language? - ✔✔Obtain a
medical interpreter.
✔✔Which factor is considered best practice for triage? - ✔✔Specific education and
competency for the area
✔✔Using the CIAMPEDS mnemonic, the triage nurse evaluates fever control for a
pediatric patient. This reflects which component of the mnemonic? - ✔✔Medication
✔✔The CIAMPEDS mnemonic can determine which assessment parameter? - ✔✔Last
meal
✔✔What should the nurse do when a person calls on the telephone for medical advice?
A. Answer simple questions, such as those related to fever control.
B. Politely inform the caller that the emergency department does not give out any
medical advice.
C. Transfer the call to a licensed independent care practitioner.
D. Determine what the problem is. - ✔✔B. Politely inform the caller that the emergency
department does not give out any medical advice.
QUESTIONS SET A+
✔✔A pediatric patient with increased work of breathing is likely to display which
assessment finding?
A. Grunting
B. Shallow respirations
C. Decreased breath sounds
D. Unlabored breathing - ✔✔A. Grunting
A pediatric patient with increased work of breathing is likely to display grunting, nasal
flaring, tripod positioning, an increased respiratory rate for his or her age, stridor,
labored breathing, accessory muscle use, and head bobbing. Shallow respirations and
decreased breath sounds are signs of decreased work of breathing. Unlabored
breathing is a normal finding.
✔✔The triage nurse should be aware of which performance improvement measure? -
✔✔The acceptable arrival time to triage time
✔✔When triaging a potential psychiatric patient, which action is the triage nurse's
priority? - ✔✔Assess patient and staff safety.
✔✔When triaging a geriatric patient, the triage nurse should routinely perform which
action?
A. Speak loudly to older adults.
B. Use only closed-ended questions to obtain medical history.
C. Determine if the patient has a plan to hurt others.
D. Evaluate the patient's interactions with his or her family. - ✔✔D. Evaluate the
patient's interactions with his or her family.
Admission to the emergency department gives the triage nurse a chance to evaluate the
patients interactions with his or her family. Emergency medical services may provide
, valuable information about the patients living conditions and ability to manage activities
of daily living. Also, screen for older adult abuse and neglect. Use various open-ended
and closed-ended questions to obtain information, including medical history.
Determining whether the patient has a plan for hurting others is appropriate for an older
adult patient who presents with behavioral health concerns. When speaking to an older
adult patient, block out extraneous noise and speak slowly, facing the patient. You do
not necessarily need to speak loudly.
✔✔Which measure best protects patients, staff and visitors from violence in the
emergency department?
A. Presence of plain-clothed security personnel
B. Unrestricted visitor access
C. Staff training in crisis intervention
D. Closed-circuit cameras in triage that can be activated as needed - ✔✔C. Staff
training in crisis intervention
Emergency department staff members must be able to recognize an escalating situation
and intervene appropriately. Security personnel should be visible and uniformed with a
commanding presence. Emergency departments should have a visitor policy that
identifies visitors with passes or badges to control access into the department.
Surveillance of strategic locations, such as emergency department entrances, waiting
areas, and triage rooms, should occur continuously rather than as needed.
✔✔What is the safest way to obtain information from a patient who does not speak
English or is more comfortable speaking in his or her native language? - ✔✔Obtain a
medical interpreter.
✔✔Which factor is considered best practice for triage? - ✔✔Specific education and
competency for the area
✔✔Using the CIAMPEDS mnemonic, the triage nurse evaluates fever control for a
pediatric patient. This reflects which component of the mnemonic? - ✔✔Medication
✔✔The CIAMPEDS mnemonic can determine which assessment parameter? - ✔✔Last
meal
✔✔What should the nurse do when a person calls on the telephone for medical advice?
A. Answer simple questions, such as those related to fever control.
B. Politely inform the caller that the emergency department does not give out any
medical advice.
C. Transfer the call to a licensed independent care practitioner.
D. Determine what the problem is. - ✔✔B. Politely inform the caller that the emergency
department does not give out any medical advice.
