BCEN CPEN Exam Questions

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181.

A nine-year-old male is admitted to the emergency department after a hit to the head during a football game. The trauma happened approximately 24 hours ago. The patient's mother is concerned about the bruising that has formed, and the child complains of intense pain. The nurse notes a positive Battle's sign upon physical examination. This an indication of which type of fracture?

  • Of the middle cranial fossa of the skull

  • Of the posterior cranial fossa of the skull

  • Of the anterior cranial fossa of the skull

  • Of the mandibular condyle

Correct answer: Of the middle cranial fossa of the skull

The middle cranial fossa is a butterfly-shaped depression of the skull base and houses the temporal lobes of the cerebrum. Battle's sign, also referred to as mastoid ecchymosis, indicates a fracture of the middle cranial fossa of the skull. It represents postauricular hematoma and swelling from damage to the sigmoid sinus temporal bone, indicating a serious head injury.

Battle's sign generally takes at least one day to manifest after the initial traumatic basilar skull fracture and consists of bruising over the mastoid process (a crescent-shaped bruise behind one or both ears) as a result of extravasation of blood along the path of the posterior auricular artery.

Do not confuse Battle's sign with a spreading hematoma from a fracture of the mandibular condyle, which is a less serious injury.

182.

A child presents to the emergency department with abrupt-onset, large-volume hemoptysis secondary to right lower lobe pneumonia that the patient has been battling for approximately two weeks. The child does not have any underlying pulmonary, cardiac, hematologic, or neoplastic disease but is coughing up significant amounts of blood. The child requires airway stabilization with intubation and mechanical ventilation, and the emergency team is preparing for a blood transfusion.

Which of the following tests, if ordered by the physician, is diagnostic for pulmonary hemorrhage?

  • Sputum or gastric aspirate revealing hemosiderin in the lung

  • Hematocrit, reticulocyte count, and stool sample for occult blood

  • Culture of bronchoalveolar lavage (BAL) samples via bronchoscopy

  • Chest radiographs with at least two views to detect the site and extent of bleeding

Correct answer: Sputum or gastric aspirate revealing hemosiderin in the lung

Infection is the most common cause of hemoptysis in children without an underlying disease. It can be caused by pneumonia or a lung abscess, tuberculosis, or aspergilloma. Influenza virus may present with significant bleeding, and infections with relatively common community-acquired organisms such as Staphylococcus, Streptococcus, Klebsiella, and Pseudomonas can also cause hemoptysis.

Initial management for patients with large-volume hemoptysis includes airway stabilization and prevention of further bleeding. Once the patient is stable, laboratory work is performed (acute hemorrhage is accompanied by a drop in hematocrit, an increased reticulocyte count, and a stool positive for occult blood). Chest radiography may indicate the site and extent of the bleeding, and culturing of BAL samples for bacteria, viruses, and fungi will help exclude infectious processes.

A diagnosis of pulmonary hemorrhage is most readily confirmed with the detection of hemosiderin-laden macrophages in sputum or gastric aspirate using Prussian blue staining.

183.

Which of the following findings indicates cardiac tamponade?

  • Narrow pulse pressure

  • Hypertension

  • Bradycardia

  • Low central venous pressure (CVP)

Correct answer: Narrow pulse pressure

Cardiac tamponade can occur from a contusion or from penetrating trauma, resulting in blood or fluid accumulation in the pericardial sac. This accumulation of fluid around the heart impairs ventricular filling, reduces cardiac output (CO), and causes hypotension (not hypertension) due to decreased preload. A narrow pulse pressure is the result of increased diastolic pressure to compensate for the low CO, as the external pressure on the heart inhibits the ventricles from relaxing.

CVP is elevated in cardiac tamponade, not decreased. Tachycardia is present, not bradycardia.

184.

A child who has been exposed to anthrax presents to the emergency department (ED) for treatment. As the triage nurse on duty, you should prioritize which of the following assessments?

  • Respiratory status assessment

  • Skin assessment

  • Assess for signs of hemorrhage

  • Neurologic assessment

Correct answer: Respiratory status assessment

Anthrax exposure via inhalation presents with nonspecific flu-like symptoms initially, followed by abrupt onset of respiratory failure, including stridor, cyanosis, hypoxia, diaphoresis, hypotension, and shock (hemodynamic collapse). After respiratory symptoms set in, patients have a high mortality rate. For this reason, respiratory status should be prioritized, followed by assessing neurologic status, signs of hemorrhage, and skin.

185.

Which of the following medications is not implicated as a trigger for Stevens-Johnson syndrome (SJS)?

  • Acyclovir

  • Amoxicillin

  • Trimethoprim/sulfamethoxazole

  • Phenytoin

Correct answer: Acyclovir

SJS is a potentially life-threatening, exfoliative skin disease that occurs from an immunologic reaction to a drug or virus; it also can be completely idiopathic. Children are typically admitted to the pediatric intensive care unit (PICU) or burn unit for wound care, management of hydration and electrolyte issues, nutritional support, and pain control.

The most important first treatment is the removal of the causative agent if known. IVIG can be started to reverse the blistering and sloughing of the skin. The use of systemic corticosteroids is contraindicated in the treatment of SJS because of the increased risk of sepsis.

Acyclovir has not been shown to induce SJS. All the other options (penicillins including amoxicillin, sulfonamides including Bactrim, and anticonvulsants including phenytoin) are potential triggers.

186.

A 14-year-old patient is in the PICU with peritonitis and has a nasogastric (NG) tube in place due to the presence of an ileus. The nurse anticipates administering which of the following medications to increase gastric motility?

  • Metoclopramide (Reglan)

  • Sucralfate (Carafate)

  • Ranitidine (Zantac)

  • Famotidine (Pepcid)

Correct answer: Metoclopramide (Reglan)

Metoclopramide is an antiemetic and a gut-motility stimulator; it improves gastric motility.

Sucralfate is used to treat and prevent ulcers, coating the ulcer and thereby protecting the area from further injury. Ranitidine and famotidine are often used in the treatment of gastroesophageal reflux disease (GERD).

187.

A concerned mother brings her two-week-old infant into the emergency department regarding a "lump" on her baby's head that, per her pediatrician, was a collection of blood between the skull bone and its covering. After a thorough assessment of the infant, who does not have any other symptoms and appears healthy, the nurse reiterates the doctor's explanation of the finding.

What is this condition called?

  • Cephalohematoma

  • Craniosynostosis

  • Subdural hematoma

  • Caput succedaneum

Correct answer: Cephalohematoma

Cephalohematoma is a collection of blood between the skull and the periosteum. It does not extend across cranial suture lines and can occur following a traumatic vaginal delivery (forceps- or vacuum-assisted). A cephalohematoma can take up to 3 weeks to resolve, depending on the size.

Caput succedaneum is swelling of the tissue from an increase in serous fluid over the presenting part of the fetal head caused by pressure during labor. Subdural hematoma (SDH) refers to bleeding between the dural and arachnoid membranes of the brain. Craniosynostosis is the premature closure of one or more cranial sutures.

188.

You are triaging a teenager with type 1 diabetes mellitus who presents with lethargy, slurred speech, and emesis. You suspect which of the following? 

  • Increased intracranial pressure (ICP) 

  • Presence of a brain tumor

  • Hypoglycemia

  • Alcohol or drug poisoning 

Correct answer: Increased intracranial pressure (ICP)

This patient's assessment findings are consistent with increasing ICP, which is a potential complication (along with cerebral edema) of diabetic ketoacidosis (DKA). Other manifestations of increasing ICP and cerebral edema include visual changes, speech disturbances, and motor weakness. 

If this patient did not have diabetes mellitus, the other choices would be possible causes (brain tumor, hypoglycemia, or poisoning) of their symptoms. 

189.

A 12-year-old male trauma patient presents to the emergency department accompanied by his mother, after a fall while attempting to do tricks on his bike. He reports he flipped over the bike, and his stomach hit the handlebars before he crashed. He complains of diffuse abdominal pain, nausea, and vomiting. The patient's laboratory results reveal an elevated serum amylase.

Which organ was most likely injured? 

  • Pancreas

  • Liver

  • Spleen

  • Kidney

Correct answer: Pancreas

The pancreas, located deep in the upper abdomen, is not frequently injured unless a significant sustained force compresses it against the spine. The classic injury is compression by bicycle handlebars. Other mechanisms may include motor vehicle collisions and child maltreatment. Signs and symptoms may include diffuse abdominal tenderness, deep epigastric pain radiating to the back, and bilious vomiting. Serum amylase is elevated. A diagnosis is usually made by an abdominal CT scan with IV contrast. Management depends on injury severity.

Renal injury presents with hematuria, flank pain, and abdominal pain. Splenic injury generally leads to left shoulder pain, and patients with liver trauma experience right shoulder pain as a part of their symptomatology.

190.

A pediatric critical care nurse is preparing to admit a nine-year-old male from the ER with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse is told the child is confused and tachycardic with a blood pressure reading of 132/92 and a sodium level of 90.

What type of intravenous management will the doctor probably order for this patient?

  • Hypertonic IV solution and furosemide (Lasix)

  • Hypotonic IV solution and furosemide (Lasix)

  • Hypertonic IV solution and ADH replacement

  • Hypotonic IV solution and ADH replacement

Correct answer: Hypertonic IV solution and furosemide (Lasix)

SIADH is a common disorder in pediatric critical care and occurs when ADH release cannot be suppressed. This excess ADH will result in hyponatremia (serum sodium <135 mEq/L) and impaired water excretion. Treatment goals include normalizing serum sodium and serum osmolality (which are both low) over 48 to 72 hours, as well as decreasing extravascular fluid volume, treating the underlying disorder, preventing neurologic sequelae, and preventing reoccurrence with careful management.

Slow and careful IV administration of a hypertonic solution (i.e., 3% NaCl) is indicated, and sodium correction should be no faster than 0.5 mEq/L/hr. If hypervolemia is present or persists, a loop diuretic like Lasix may be judiciously used. Once serum sodium levels reach 135 mol/L, fluid restriction may be lifted to a maintenance fluid rate.

ADH replacement is necessary for central diabetes insipidus (CDI), not SIADH.

191.

Which wound presents the greatest risk for tetanus infection? 

  • A puncture wound obtained while helping with gardening 

  • A laceration obtained while preparing to cook raw beef 

  • A human bite

  • An abrasion obtained by falling onto a sidewalk 

Correct answer: A puncture wound obtained while helping with gardening 

Tetanus is caused by Clostridium tetani, a gram-positive anaerobic bacillus. This organism is present in soil, in garden moss, on farms, and anywhere animal and human excreta can be found. Bacteria enter the circulation through an open wound and attach to cells within the central nervous system. The usual incubation period is 2 days to 2 weeks. As long as a patient's immunizations are current, tetanus is a completely avoidable condition. Postexposure immunizations should be given only when needed. 

Bite wounds are associated with a high risk of bacterial infection, but are not associated with tetanus. Tetanus is much more likely to be found in soil containing the tetanus-causing bacteria than in a wound from a kitchen accident dealing with raw beef. An abrasion is shallow and would not provide an anaerobic environment for the tetanus bacteria to grow. 

192.

Which of the following is correct regarding pain management in an emergency setting? 

  • Antiemetic medications are not necessary prior to administering opioids

  • Using opioids to treat abdominal pain will interfere with accurate diagnosis

  • Neonates do not require analgesic medications

  • Opioid-dependent patients do not require more pain medications than opioid-naive patients

Correct answer: Antiemetic medications are not necessary prior to administering opioids

The idea that antiemetic medications are necessary prior to administering opioids is a common pain management myth. 

Other pain management myths include the following: using opioids to treat abdominal pain will interfere with an accurate diagnosis, neonates do not require analgesic medications, and opioid-dependent patients do not require more pain medications than opioid-naive patients.

193.

Diagnostic criteria for Kawasaki disease (KD) include which of the following?

  • Fever persisting for at least 5 days plus the presence of four or more of the five principal features

  • Fever persisting for at least 4 days plus the presence of 3 or more of the 5 principal features

  • Fever persisting for at least 5 days plus the presence of 2 or more of the 5 principal features

  • Fever persisting for at least 4 days plus the presence of 4 or more of the 5 principal features

Correct answer: Fever persisting for at least 5 days plus the presence of four or more of the five principal features

KD is microvasculitis of the medium-sized muscular arteries. It is most likely a disease of the immune system triggered by an infectious event. Multisystem vasculitis (particularly in the coronary arteries) is followed by pancarditis with inflammation of the conduction system, myocardium, pericardium, and endocardium. Myocarditis develops within 3 to 4 weeks and is associated with white blood cell infiltration, elevated platelet counts, and edema of the conduction system and myocardial muscle.

Diagnostic criteria include a fever that persists for at least 5 days, plus the presence of four or more of the following five principal features:

  • polymorphous exanthema of the trunk
  • swollen lymph nodes
  • strawberry tongue, diffuse injection of the oral mucosa, erythema, and cracking of lips
  • edema and erythema of the hands and feet (acute phase) with membranous desquamation of fingertips (convalescent phase)
  • bilateral conjunctival injection of the eyes without exudate

194.

A child has developed diabetes insipidus (DI) after undergoing pituitary surgery and is having large quantities of dilute urine. What is the most likely reason behind this symptom?

  • A deficiency of antidiuretic hormone (ADH)

  • Low serum osmolality

  • Low serum sodium levels

  • High serum glucose levels

Correct answer: A deficiency of antidiuretic hormone (ADH)

DI is caused by either an insufficient secretion of ADH (central) or failure of the kidneys to respond to ADH (nephrogenic). Central DI is the most common form of DI; deficient ADH levels are due to failure of the hypothalamus to produce ADH or failure of the kidneys to respond to ADH. This results in an inability to concentrate urine, leading to high volumes of dilute urine (polyuria) with high serum osmolality and hypernatremia.

Causes of CDI may include pituitary or suprasellar surgery, TBI, brain tumors, CNS infections or malformations, leukemias or lymphomas, cerebral edema, or brain death.

Serum glucose levels are generally not affected by DI.

195.

A child presents to the emergency department (ED) after falling through ice on a frozen lake. After receiving several normal saline boluses, the child is intubated and mechanically ventilated in the field and is now on epinephrine and dopamine drips. The child continues to be hypotensive secondary to which of the following pathophysiologic factors?

  • Decreased venous return

  • Decreased pulmonary vascular resistance (PVR)

  • Decreased systemic vascular resistance (SVR)

  • Decreased intrathoracic pressure

Correct answer: Decreased venous return

After drowning, patients require positive pressure ventilation (PPV) caused by increased (not decreased) intrathoracic pressure, leading to decreased venous return. Cardiac pathophysiologic changes associated with submersion injury are the consequence of hypoxia and acidosis. Hypoxemia produces hypoxic-ischemic cardiovascular injury, resulting in decreased cardiac output, elevated right and left heart filling pressures, increased PVR, and increased SVR.

196.

Which statement is correct about the uncompensated phase of shock?

  • A classic sign is an increase in capillary permeability

  • This phase of shock results in irreversible injury, bradycardia, and profound hypotension

  • The body attempts to use hormonal, neural, and biochemical responses in this phase of shock

  • Vasoconstriction results in cool, pale, or mottled and diaphoretic skin

Correct answer: A classic sign is an increase in capillary permeability

Uncompensated shock is the result of the body's compensatory mechanisms failing and causing multisystem organ failure. During the compensatory stage (before uncompensated shock occurs), the body can adapt for a period, so major organs do not show failure. The body attempts to use hormonal, neural, and biochemical responses to compensate, and vasoconstriction results in cool, pale, or mottled and diaphoretic skin.

The cascade of physiologic changes in uncompensated shock includes the loss of autoregulation in the microcirculation, leading to an increase in capillary permeability, third spacing, and decreased venous return. Mental status deteriorates as the brain becomes hypoxic, and acute renal failure occurs. Finally, if dynamic treatment is not received or is unsuccessful, the patient moves into the final phase of shock, which is the refractory phase. This phase is marked by unmanageable and irreversible injury, bradycardia, profound hypotension, organ failure, and ultimately death.

197.

What is the most common clinical manifestation of systemic anaphylaxis? 

  • Hives

  • Gastrointestinal upset 

  • Airway obstruction 

  • Edema of the lips and face 

Correct answer: Hives

Clinical signs and symptoms typically occur within minutes of exposure to the antigen and are the result of the action of inflammatory mediators on surrounding tissues and blood vessels. An initial mild reaction can rapidly progress to life-threatening symptoms. The most common assessment finding is hives (urticaria), followed by angioedema. 

Respiratory compromise and cardiovascular collapse are of the greatest concern but are less common. Gastrointestinal upset is experienced by a smaller percentage of individuals during an anaphylaxis episode. 

198.

A pediatric nurse is providing discharge instructions to the caregivers of a child with Kawasaki disease (KD). Which of the following symptoms, if exhibited by the child, should warrant an immediate call to the child's pediatrician?

  • Fever

  • Joint pain

  • Irritability

  • Desquamation of the hands and feet

Correct answer: Fever

KD is microvascuitis of medium-sized muscular arteries. This rare disease causes inflammation of the blood vessels throughout the body and is likely a disease of the immune system triggered by an infectious event. It is more prevalent in children of Japanese ancestry and in those younger than five years of age.

Upon discharge of a child with KD, their caregivers should be instructed to check the temperature of the child every 6 hours for the first 48 hours following the last fever and then daily until the follow-up visit. A new fever could indicate a recurrent episode of KD and should warrant an immediate return to the hospital.

Irritability is a hallmark finding in a child with KD, and parents should be advised that this symptom can last for up to two months following the acute phase of the disease. Temporary joint pain and other manifestations of arthritis may occur and persist for several weeks. ROM exercises and warm baths will help reduce these symptoms and minimize discomfort. Skin peeling is an expected finding. Parents should be informed that the peeling itself is not painful, but the new skin underneath may be red and sore.

199.

A nurse is caring for an intubated, mechanically ventilated child. The child suddenly becomes notably pale and has diminished peripheral pulses. Hemodynamic monitoring reveals decreased oxygenation. What is the priority nursing action in this scenario?

  • Call the physician and prepare for needle decompression

  • Administer IV sedatives and neuromuscular blocking agents

  • Administer an IV bolus of normal saline

  • Prepare the patient for chest radiographs

Correct answer: Call the physician and prepare for needle decompression

Air leak syndromes (e.g., pneumothorax, pneumomediastinum, pneumopericardium, and pneumoperitoneum) are complications of mechanical ventilation as a result of large tidal volumes and/or high pressure. The physician should be immediately notified in this scenario, and the nurse should prepare for needle decompression. A chest x-ray will be indicated after the procedure to verify the resolution of the pneumothorax.

Administering sedation and neuromuscular blocking agents is indicated in the diagnosis of pulmonary hypertension. A fluid bolus would be necessary in the case of hypotension.

200.

A three-month-old infant is admitted to the emergency department with suspected tricuspid atresia (TA). Which of the following findings on electrocardiogram (ECG) is indicative of this condition?

  • Left axis deviation

  • Right axis deviation

  • Increased right ventricular (RV) forces

  • Diminished left ventricular (LV) forces

Correct answer: Left axis deviation

Most forms of congenital heart disease show right axis deviation and right heart strain. With tricuspid atresia (TA), the right ventricle is bypassed, and the left ventricle ends up doing all the work. The lack of tricuspid valve formation results in the absence of blood flow from the right artery (RA) to the right ventricle (RV) and poor RV formation in utero.

ECG shows a superior and leftward QRS axis, RA enlargement, absent or diminished RV forces, and increased LV forces. Survival is contingent upon the placement of an obligatory right-to-left atrial shunt.