Healthstream CEN Assessment-
Questions & Answers
3yo male pt w. hx of ventriculoperitoneal (VP) shunt placement admitted to neuro ICU w.
positive Brudzinski's & Kernig's signs which indicate Correct Ans-CNS infx - Kernig's is
inability to straighten leg when hip flexed 90 degrees. Brudzinski's is flexion of hips & knees
that occurs when neck is flexed. Both signs, when positive, indicate meningitis
62yo pt referred for fibrinolytic therapy for suspected stroke. Nurse knows the most important
factor w. this therapy is to Correct Ans-Obtain accurate hx of s/s onset - Onset of s/s is
essential for proper timing & administration of fibrinolytic products for suspected stroke.
Fibrinolytics should ideally be administered w/in 3h after onset of s/s. Exceptions occasionally
made for certain pts w. onset of s/s up to 4.5h prior to tx
Mother of 2yo states she found spilled bottle of Tylenol on floor of bathroom at 11 Correct
Ans-30 am & suspects child ingested significant number of pills this AM. At 4 pm,
acetaminophen level 145 mcg/ml. Nurse should expect to:Administer N-acetylcysteine
(Acetadote) - N-acetylcysteine is antidote to acetaminophen OD, & has highest hepatoprotection
when given w/in 8h of ingestion
Nurse receives report that a 67yo female is being brought in unconscious from house fire. Nurse
knows that which device may provide inaccurate reading on this pt Correct Ans-Pulse ox -
Pulse oxs are unable to distinguish btw oxyhemoglobin & carboxyhemoglobin. ABG is a more
reliable gauge of pts true blood oxygen levels. Carboxyhemaglobin levels should be monitored
as well
, Nurse assesses burn trauma victim w. "Rule of Palms" to determine percentage of BSA affected.
Method Correct Ans-Pts palm = 1% of BSA - Palm doesn't include wrist or fingers
ED charge nurse is making nursing assignments for night shift. Which nurse should NOT be
assigned to care pt dx w. active herpes zoster infx Correct Ans-Nurse who's never had
chicken pox - Herpes zoster is virus that causes chicken pox & shingles. Nurse who has never
had chicken pox shouldn't be exposed to pt
Nurse is planning care for hallucinating & delusional pt whose been rescued from suicide
attempt. Nurse plans to Correct Ans-Initiate 1:1 suicide precautions immediately - 1:1 suicide
precautions required for pt rescued from suicide attempt, especially if pt is also delusional &
hallucinating. These factors increase r/o unpredictable behavior & suicide
23yo male arrives at ED for injuries from gang shooting spree. Paramedics report pt made
numerous verbal threats to kill them, & patient presentation suspicious for illicit drug use. MOST
important consideration while caring for pt is Correct Ans-Maintain safety of pt & caregivers
- Pts safety threatened by his injuries & possibility of rival gang members being admitted to
same unit. Caregiver safety jeopardized by pts threats of violence & AMS d/t possible drug use
Mother brings 4mo male to ED bc he "isn't acting right." Mother reports infant sat up suddenly
while lying on changing table, & hit head on cabinet. Upon exam, nurse notes infant lethargic but
VS normal. In addition to neuro eval, nurse should consider Correct Ans-Notifying
appropriate state child protection agency - 4mo isn't likely to have muscular development
necessary to sit upright w. such force to cause neuro injury from hitting head on cabinet. Infant
trauma that doesn't correlate w. caregiver reporting should be considered suspicious for abuse, &
reported to appropriate child protection agency
Questions & Answers
3yo male pt w. hx of ventriculoperitoneal (VP) shunt placement admitted to neuro ICU w.
positive Brudzinski's & Kernig's signs which indicate Correct Ans-CNS infx - Kernig's is
inability to straighten leg when hip flexed 90 degrees. Brudzinski's is flexion of hips & knees
that occurs when neck is flexed. Both signs, when positive, indicate meningitis
62yo pt referred for fibrinolytic therapy for suspected stroke. Nurse knows the most important
factor w. this therapy is to Correct Ans-Obtain accurate hx of s/s onset - Onset of s/s is
essential for proper timing & administration of fibrinolytic products for suspected stroke.
Fibrinolytics should ideally be administered w/in 3h after onset of s/s. Exceptions occasionally
made for certain pts w. onset of s/s up to 4.5h prior to tx
Mother of 2yo states she found spilled bottle of Tylenol on floor of bathroom at 11 Correct
Ans-30 am & suspects child ingested significant number of pills this AM. At 4 pm,
acetaminophen level 145 mcg/ml. Nurse should expect to:Administer N-acetylcysteine
(Acetadote) - N-acetylcysteine is antidote to acetaminophen OD, & has highest hepatoprotection
when given w/in 8h of ingestion
Nurse receives report that a 67yo female is being brought in unconscious from house fire. Nurse
knows that which device may provide inaccurate reading on this pt Correct Ans-Pulse ox -
Pulse oxs are unable to distinguish btw oxyhemoglobin & carboxyhemoglobin. ABG is a more
reliable gauge of pts true blood oxygen levels. Carboxyhemaglobin levels should be monitored
as well
, Nurse assesses burn trauma victim w. "Rule of Palms" to determine percentage of BSA affected.
Method Correct Ans-Pts palm = 1% of BSA - Palm doesn't include wrist or fingers
ED charge nurse is making nursing assignments for night shift. Which nurse should NOT be
assigned to care pt dx w. active herpes zoster infx Correct Ans-Nurse who's never had
chicken pox - Herpes zoster is virus that causes chicken pox & shingles. Nurse who has never
had chicken pox shouldn't be exposed to pt
Nurse is planning care for hallucinating & delusional pt whose been rescued from suicide
attempt. Nurse plans to Correct Ans-Initiate 1:1 suicide precautions immediately - 1:1 suicide
precautions required for pt rescued from suicide attempt, especially if pt is also delusional &
hallucinating. These factors increase r/o unpredictable behavior & suicide
23yo male arrives at ED for injuries from gang shooting spree. Paramedics report pt made
numerous verbal threats to kill them, & patient presentation suspicious for illicit drug use. MOST
important consideration while caring for pt is Correct Ans-Maintain safety of pt & caregivers
- Pts safety threatened by his injuries & possibility of rival gang members being admitted to
same unit. Caregiver safety jeopardized by pts threats of violence & AMS d/t possible drug use
Mother brings 4mo male to ED bc he "isn't acting right." Mother reports infant sat up suddenly
while lying on changing table, & hit head on cabinet. Upon exam, nurse notes infant lethargic but
VS normal. In addition to neuro eval, nurse should consider Correct Ans-Notifying
appropriate state child protection agency - 4mo isn't likely to have muscular development
necessary to sit upright w. such force to cause neuro injury from hitting head on cabinet. Infant
trauma that doesn't correlate w. caregiver reporting should be considered suspicious for abuse, &
reported to appropriate child protection agency
