CPEN IV ANSWERS & RATIONALES (2023)

QUESTION ONE (Pediatric Assessment Triangle): The correct answer is C. The child has an abnormal finding to the circulation to skin (flushed) but has normal findings to the other two components of the Pediatric Assessment Triangle. However, the caregiver is concerned about the child and has brought the child to the ED, therefore, the baseline level that should be assigned is “sick”. Since one of the components is altered, then the baseline “sick” is increased to “sicker.” Had two or more of the components of the pediatric assessment triangle been altered, then “sickest” would be most appropriate.

QUESTION TWO (Gender Identity): The correct answer is B. Gender-affirming medications, both androgen and estrogen, increase the risk of thromboembolism complications. Menstruation-inhibiting medications, such as norethindrone, also have an increased risk of thromboembolism. Based on this patient’s Presentation, the most appropriate course of action is to assign a triage acuity based on this high risk. While genotypic (XY) males, ages 13-18, who smoke, are at increased risk for spontaneous pneumothorax but this question indicates a tension pneumothorax, this patient does not meet any of those criteria other than age. They are stated to be not assigned male at birth and we are not given information on if they smoke, so while possible, it is not a higher priority than assessing for VTE. While offering privacy, calming techniques, and resources are all valid options, they are not of a higher priority than identifying and correctly a credible, life-threatening condition. Therefore, the most appropriate answer is B.

QUESTION THREE (Disaster Management): The correct answer is B. The response stage of disaster management begins when the hospital is either notified of an impending disaster (e.g., hurricane) or when they are notified that a disaster situation has occurred (e.g., train derailment). At this point, the steps of response begin (taking actions to save lives and prevent further damage). Many steps in the response stage of disaster management will likely have taken place before the first patient arrives and before the central command center is established. Establishment and staffing of the "black", "red", "yellow" and "green" patient care areas occur after the disaster has been identified as a result of activation of the disaster plan. Therefore, while the establishment of these areas is part of the response phase of disaster management, they do not mark the beginning of this phase.

QUESTION FOUR (Primary and Secondary Assessment): The correct answer is D. A respiratory rate of 16 is considered bradypnea in a 2-year-old and would be concerning. Generally, this respiratory rate would not support ventilatory needs and would require treatment or investigation. A pulse of 130 beats per minute, an end-tidal carbon dioxide of 40 mm Hg, and a systolic blood pressure of 86 mm Hg are considered normal for this age and are not concerning.

QUESTION FIVE (Newborn Resuscitation): The correct answer is B. A newborn who is breathing, crying, and has good tone is considered normal findings and does not indicate the need for advanced intervention. However, all newborns are at risk for hypothermia and require the intervention of drying, applying warmth, and, at minimum, providing gentle stimulation. Nothing in this scenario indicates this patient has a volume deficit or that a fluid bolus would be a higher priority than warming. A neonate’s respiratory pattern is expected to be irregular and is not the reason for concern. At one minute after delivery, the expected SpO2 is 60-65% or higher; therefore, this patient is above the expected saturation and does not warrant any supplemental oxygen. While positive pressure ventilation may be beneficial, they are not indicated in this case and the rate of 20-30 is too low for a newborn; which should be 40-60.

QUESTION SIX (Pain Assessment): The correct answer is B. One of the developmental tasks of 3 – 5 years of age is to point to pain, describe it and quantify it.  A 2-year-old may be able to localize pain but would not be able to describe or quantify it.  By six years of age (and beyond), these tasks should be mastered, and the child should be able to verbalize pain as well as its intensity.

QUESTION SEVEN (Cystic Fibrosis): The correct answer is A. The sweat chloride test is used to diagnose cystic fibrosis. Acute tubular necrosis is more likely to be recognized with renal function tests and urinalysis. Tracheal stenosis is diagnosed by imaging studies rather than sweat chloride testing. Hyperosmolar hyperglycemic syndrome is most likely to be recognized by serum blood sugar measurements as opposed to a sweat chloride test.

QUESTION EIGHT (Asthma): The correct answer is D. A spacer (aerochamber) reduces the number of simultaneous steps that are required to deliver medication when compared to using a metered dose inhaler without a spacer, therefore a spacer is easier to use and takes less coordination. Spacers do not deliver medication deeper into the airways or increase the amount of medication that is delivered per puff. Metered dose inhalers do not cause damage to the mucosal tissues of the upper airway; therefore, a spacer would not reduce the incidence of this.

QUESTION NINE (Airway Adjuncts): The correct answer is C. A laryngeal mask airway (LMA) is indicated for this patient’s size, and it is indicated to control tongue obstruction, fluids in the airway, and controls the airway in the unresponsive patient. The OPA would control the tongue obstruction but would not help with the bleeding in the airway; therefore, it is not the most effective choice. The NPA is indicated for a decreased LOC but would not help with the tongue obstruction or bleeding; therefore, it would not be the most effective choice. The Combitube airway device would be a good choice except it is not indicated for patients below 4 feet (48 inches) in height which typically occurs between approximately 6-8 years of age.

QUESTION TEN (Congenital Heart Defects): The correct answer is C. Cardiac conditions in the neonate often cause tachypnea but do not cause an increased work of breathing (such as nasal flaring or retractions) whereas respiratory conditions cause tachypnea with an increased work of breathing.  Patients with cardiac conditions will almost always have tachypnea rather than bradypnea or a normal rate of breathing.

QUESTION ELEVEN (Shock): The correct answer is A. Distributive shock is caused by vasodilation. Allergic reactions, especially severe ones that result in anaphylaxis cause an inflammatory response which includes vasodilation. Therefore, allergies are most likely to contribute to distributive shock. Bradycardia is most likely to contribute to cardiogenic shock (bradycardia can also result from neurogenic shock but doesn’t cause neurogenic shock). Renal failure and hypoglycemia are not associated with shock.

QUESTION TWELVE (Circulatory Support): The correct answer is B. A patient with a left ventricular assist device who has instability and signs of shock requires resuscitation similar to any other patient. The LVAD will be assessed as part of the resuscitation, but if the child requires defibrillation, medication, or even compressions, they should not be withheld due to their history of having a ventricular assist device in place. Calling the LVAD Center is a good idea to get a consultation, but it does not take precedence over life-saving interventions for an unstable child. The majority of LVADs today are continuous flow devices, which do not generate a pulse; therefore, checking a pulse will not be possible. Likewise, without a pulse, the pulse oximetry device will likely not be able to calculate the oximetry and standard blood pressure will not be possible as the pressure will remain constant without fluctuation. Assessing the mean arterial pressure by doppler would be more appropriate for a patient with an LVAD. A normal finding of LVADs is the continuous hum that should be heard or palpated on the chest which indicates the device is functioning. This “buzzing” is not an alarm and would not be changed with a 90-gauss donut-shaped magnet.

QUESTION THIRTEEN (Stroke): The correct answer is A. 80% of neonatal strokes result in a seizure. In rare cases, feeding difficulties, unilateral motor deficits may occur but those are less common than a seizure. Elevations in body temperature are not associated with neonatal strokes.

QUESTION FOURTEEN (Headaches): The correct answer is C. Dopamine receptor antagonists may cause extrapyramidal reactions which include unusual muscular movements (such as torticollis or tortipelvic crisis.) These drugs are not associated with loss of appetite, ringing in the ears or petechial lesions.

QUESTION FIFTEEN (Spinal Cord Injury): The correct answer is B. The vertebrae of infants and toddlers have smoother surfaces and slide over one another easier than older children such as school-aged children and adolescents. Similarly, the ligaments of infants and toddlers are laxer than their older counterparts. For this reason, younger children are at an increased risk of having spinal cord injuries without radiological abnormalities than older children. SCIWORA can occur in multiple mechanisms of injury, including sporting incidents, frontal motor vehicle collisions, and side-impact motor vehicle collisions. Because of the larger head in proportion to the body of infants and toddlers, the cervical spine is at higher risk for spinal cord injuries, including SCIWORA than the thoracic spine.

QUESTION SIXTEEN (Crohn’s Disease): The correct answer is D. Children with Crohn's disease will often present with signs of malnutrition before other symptoms of the disease begin to show up. Signs of malnutrition may include growth abnormalities (slowed growth velocity) and pubertal delay. Perianal fistulas and bright red rectal bleeding can be associated with Crohn's disease, but these are often findings noted later in the disease and are unlikely to be the initial symptom. The pain of Crohn's disease is often in the lower quadrants of the abdomen rather than the epigastric region.

QUESTION SEVENTEEN (Abdominal Trauma): The correct answer is C. Hematomas of the duodenum often present as vague abdominal pain and vomiting 5 to 7 days after the injury. This is related to obstruction of the lumen of the bowel. A patient with a ruptured diaphragm is more likely to present with acute abdominal pain and shortness of breath at the time of injury. A grade III splenic injury is more likely to present with left upper quadrant pain and hypotension at the time of injury. A vertebral fracture with compression of a spinal nerve is more likely to present with acute back pain at the time of injury.

QUESTION EIGHTEEN (Sexually Transmitted Infections): The correct answer is C. Co-infections of Syphilis and HIV have been reported as rising since 2001 and in 2021, the CDC reported a 36% increase in reported co-infections in the US; primarily amongst MSM. The exact reason varies, but the most likely reason is related to the inhibitory effects of ARV medications used for prevention or treatment of HIV on the symptoms of syphilis. Therefore, the pool from which one acquires either is much more likely to have both.

QUESTION NINETEEN (Genitourinary Emergencies): The correct answer is B. Paraphimosis, a condition where a tight foreskin cannot be protracted to its original position over the glans is frequently associated with retraction of the foreskin during urinary catheterization. Physical exertion, endotracheal intubation, and lack of barrier protection during intercourse do not increase the risk of this condition.

QUESTION TWENTY (Pelvic Trauma): The correct answer is B. A properly applied pelvic binder is placed over both greater trochanters and crosses the symphysis pubis. Enclosure of the iliac crests is not necessarily considered part of proper pelvic binder placement.

QUESTION TWENTY-ONE (Throat Infections): The correct answer is C. Strep throat is caused by Group A streptococcus. These bacteria also cause impetigo, perianal cellulitis, vaginitis, septicemia, pneumonia, endocarditis, pericarditis, osteomyelitis, myositis, cellulitis, and scarlet fever. Pancreatitis is caused by factors such as alcoholism, gallstones, cystic fibrosis, high serum calcium levels, high triglyceride levels, or abdominal injury. Group A streptococcus is not associated with pancreatitis. Iritis may follow trauma to the eye, Herpes zoster of the face, syphilis, rheumatoid arthritis, sarcoidosis, and certain medications but is not associated with Group A streptococcus. Laryngotracheobronchitis is caused by a virus, not Group A streptococcus.

QUESTION TWENTY-TWO (Chemical Burn to Eye): The correct answer is C. The pH of the eye is normally 7.4 to 7.6 so flushing should be carried out until the pH on the surface of the eye is within this range.

QUESTION TWENTY-THREE (Infestations): The correct answer is A. Pediculicides should not be applied to the eyebrows to prevent it from getting into the eyes. Nits noted on the eyebrows should be treated by applying petroleum jelly to the eyebrows twice a day for ten days. It is appropriate to keep a child with lice from going to school until treatment has been given. Lice may live on inanimate objects like bedsheets or stuffed animals. If the patient comes into contact with these, they may be re-infested. Lice will not survive without human contact every several days, so putting stuffed animals in a plastic bag away from humans for two weeks will prevent this re-infestation. It is appropriate to comb the child's hair with a fine-tooth comb and then soak the comb in pediculicide to get rid of nits in the child's hair.

QUESTION TWENTY-FOUR (Orthopedic Injuries): The correct answer is A. Acute pain when pressure is applied to the "snuff box" area of the hand is commonly associated with a scaphoid fracture. This is not common with radius fractures, compression of the ulnar nerve or humerus fractures with median nerve involvement.

QUESTION TWENTY-FIVE (Integumentary Injuries): The correct answer is C. Degloved tissue should be preserved in a similar manner to amputated body parts. It is important that the degloved piece is not immersed directly into the water because water is hypotonic and will cause the tissue to swell, decreasing the chance it can be surgically reattached. It should be sealed in a plastic bag and then immersed in a cooler with water and ice. Although degloved tissue may not always be reattached, it should be transported to the hospital for assessment to determine the feasibility of reattachment.

QUESTION TWENTY-SIX (Bleeding Disorders): The correct answer is B. Patients with hemophilia B are deficient in Factor IX, therefore treatment would involve the administration of Factor IX. Factor VIII is more likely to be administered to patients with Hemophilia A and Factor XI for patients with Rosenthal’s syndrome (originally referred to as hemophilia C). Factor X is not used in the treatment of hemophilia.

QUESTION TWENTY-SEVEN (Diabetes): The correct answer is B. Patients with hyperosmolar hyperglycemic syndrome (HHS) frequently have higher blood glucose levels than those with diabetic ketoacidosis (DKA). Because glucose is a large molecule, it tends to increase serum osmolality. Patients with DKA do not produce enough insulin to utilize serum glucose and are forced to use other sources of energy, such as fats. The metabolism of fats results in the release of ketone bodies. Because HHS patients make some insulin, they can utilize some of their blood glucose and therefore metabolize less fats, resulting in lower urine ketones. Because HHS is more insidious in its onset, patients with this condition are often sicker for a longer period of time before seeking treatment, resulting in more profound dehydration and higher blood urea nitrogen levels than is found in patients with DKA.

QUESTION TWENTY-EIGHT (Congenital Adrenal Hyperplasia): The correct answer is D. All forms of congenital adrenal hyperplasia result in a decreased production of cortisol; therefore, replacing hydrocortisone, a glucocorticoid, would be appropriate for all forms of CAH during times of increased stress to prevent adrenal crisis. While some forms of CAH are salt-wasting and may require the replacement of sodium, it is not true for all types and all severities; therefore, it is not more likely to be replaced than hydrocortisone. Only two forms of CAH cause hypokalemia and they account for less than 10% of all CAH incidences; therefore, replacement of potassium is very unlikely to be done and certainly not more likely than replacing cortisol. Testosterone, an androgen sex hormone, is over-produced in approximately 95% of CAH cases and even if it were low, it would not require emergent replacement as a higher priority than replacement of cortisol.

QUESTION TWENTY-NINE (Aggressive Behavior): The correct answer is C. Infants and toddlers may demonstrate behaviors such as temper tantrums and breath-holding. If this behavior is not addressed properly (e.g. time out), the child may go on to develop further manifestations of aggressive behavior as they age. Aggressive behavior can occur during all developmental stages of childhood, not just adolescence, and is not necessarily more prominent during the school-age years, it can be found equally in various stages of development. Although signs of aggressive behavior often start young, they can start after the age of five.

QUESTION THIRTY (Human Trafficking): The correct answer is D. It is not uncommon for the victim of human trafficking to lack personal identification because it is being held by someone else. (Or the identification is produced by someone accompanying the patient.) Although numerous other signs of human trafficking must be considered, uncharacteristically baggy clothing is not specific to this patient population. The victim of human trafficking is unlikely to refuse food or fluids. Although many victims of human trafficking do visit a healthcare provider, frequent visits, especially to the same healthcare facility, are uncommon, especially for a complaint such as renal colic.

QUESTION THIRTY-ONE (Envenomation): The correct answer is C. The effects of the venom of coral snakes may be delayed as long as 12 hours. The effects of stingray, scorpion, and rattlesnake venom are almost immediate.

QUESTION THIRTY-TWO (Carbon Monoxide Poisoning): The correct answer is B. Decreased delivery of oxygen to the tissues can result in lactic acidosis, manifested as metabolic acidosis. Because carboxyhemoglobin is red in color, indications such as circumoral cyanosis and low oxygen saturations are uncommon. Hyperreflexia is not associated with carbon monoxide poisoning. In fact, as carbon monoxide levels climb, there is a decrease in the level of consciousness which may decrease reflexive action

QUESTION THIRTY-THREE (Consent): The correct answer is B. Implied consent is used if the patient is experiencing a life- or limb-threatening condition and can’t consent for themselves and there is no appropriate person to provide express consent on their behalf.  Once a patient can or a representative has arrived, express consent should be obtained as soon as possible.

QUESTION THIRTY-FOUR (Workplace Violence): The correct answer is B. Unless an emergency condition exists, nurses should avoid entering the room or potentially violent patients until they are supported by other staff.  This prevents the onset of violence.  Scanning the room for objects that could be used as missiles, removing objects that could be used for harm, and taking part in annual training designed to protect an individual in the event of a violent episode are all appropriate interventions to reduce injury related to a violent episode but do not actually reduce the incidence of that episode from happening.

QUESTION THIRTY-FIVE (Transition of Care): The correct answer is D. Providing bedside report with opportunities for the oncoming nurse to ask questions ensures a comprehensive handoff of patient care. This method allows for real-time clarification of patient conditions, and the opportunity for the oncoming nurse to immediately assess the patient and ask questions, ensuring a complete understanding of the patient's status. While a written SBAR (Situation, Background, Assessment, Recommendation) provides structured communication, it does not allow for immediate back-and-forth communication and may not contain up-to-the-minute patient information. Providing a verbal report at the nurses’ station or to the charge nurse to pass on to the oncoming nurse are methods that can be subject to miscommunication and do not afford immediate access to the patient for assessment. Therefore, bedside report is the best method for safe transition of care.