Answer Key for the Challenge Questions found in the CEN Manual (8th Edition)

CEN Challenge Answers Cover.jpg
CEN Challenge Answers Cover.jpg

Answer Key for the Challenge Questions found in the CEN Manual (8th Edition)

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Answer Key for the 44 Challenge Questions found in the back of the CEN Manual (8th Edition)

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CEN Manual – Answer Key to Challenge Questions

Question One
The correct answer is D

Rationale: Assessing level of orientation is considered part of the neurological assessment which occurs in the primary survey.  (As part of the “D” in the ABCD mnemonic).  Inserting a urinary catheter, assessing for extraocular eye movements and assessing pain levels are all considered part of the secondary survey.

Question two
The correct answer is A

Rationale:  The inability to breathe deeply while palpating under the right costal margin (also known as Murphy’s sign) is associated with cholecystitis.  

Question three
The correct answer is B

Rationale: Epididymitis is marked by scrotal or lower abdominal pain that usually has a gradual onset and is often noted with sexual activity.  Because it is associated with an infection, a fever is not unexpected.  Priapism is a sustained erection in the absence of sexual stimulation and does not involve a fever.  Ulcerative colitis is not associated with sexual intercourse and testicular torsions have a sudden onset and are not generally associated with sexual intercourse.  

Question Four
The correct answer is C

Rationale:  Excess water in the body will dilute serum sodium levels resulting in hyponatremia.  Potassium, calcium and phosphate levels are less likely to be affected with excess body water.

Question Five
The correct answer is B
 
Rationale:  Decreased urinary output generally results in a diminished ability to rid the body of electrolytes and other wastes.  Therefore, phosphates, potassium, and creatinine tend to climb.  Because phosphates and calcium exist in an inverse relationship, an increasing phosphate level will cause calcium to be shifted into bones and teeth, diminishing serum calcium levels.

Question Six
The correct answer is C
 
Rationale:  Addison’s’ disease tends to cause hypoglycemia, hyponatremia, hyperkalemia and hypotension.  Therefore, an elevation in serum glucose would indicate effective treatment.  The other factors would all increase with effective treatment. 

Question Seven
The correct answer is A
 
Rationale:  Disseminated intravascular coagulation is marked by decreased clotting substances such as platelets and fibrinogen, which are consumed with the abnormal clotting associated with this disorder.  As clotting factors decline, the patient’s bleeding tendencies climb and prothrombin and partial thromboplastin times will elongate.  The body releases fibrin degradation products, such as D-Dimer as blood clots form throughout the body, so these will be elevated. 

Question Eight
The correct answer is D

Rationale: Patients who demonstrate severe anaphylaxis, including hypotension and indications of respiratory difficulty should receive Epinephrine 1:10,000 intravenously.  Patients who are experiencing mild anaphylaxis, including hemodynamic stability and lack of respiratory difficulty may receive Epinephrine 1:1,000 subcutaneously.  

Question Nine
The correct answer is B
Rationale: This statement reflects an authoritative, yet non-threatening statement which is meant to ensure the patient’s safety.  These are all therapeutic for this disorder.  The  patient in the manic phase of bipolar disorder should not be encouraged to speak, “yes” and “no” answers are more appropriate.  Statements made to someone in the manic phase of bipolar disorder should also be brief and succinct to prevent misinterpretation.

Question Ten
The correct answer is C

Rationale: SSRI medications, when taken in combination with other substances increases the risk of developing serotonin syndrome.   Substances that can increase this risk include other antidepressants, opioids, drugs of abuse and certain herbal medications including St. John’s Wort.  Diabetes and a shellfish allergy are unlikely to contribute to the onset of serotonin syndrome.  Overdosing on SSRI medication, rather than missing doses, contributes to serotonin syndrome. 

Question Eleven
The correct answer is D
 Rationale: Although anyone may perpetrate Munchausen syndrome by proxy, females do so with much greater frequency then males.  The perpetrator frequently has a health care background.  Munchausen syndrome by proxy is a complex form of abuse which requires significant mental faculties in order to carry out the deception required to pull of this abuse.  This makes an individual with mental disabilities a less likely perpetrator.

Question Twelve
The correct answer is A
Rationale: Once transcutaneous pacing is initiated, it is important to ensure mechanical capture occurs with each electrical impulse.  This is best accomplished by palpating the pulse and making sure there is a palpable beat with each pacing spike.  The carotid pulse should not be used for this assessment as contraction of the chest and neck muscles caused by the pacemaker may be mistaken for a pulse.  Other sites, such as the femoral artery should be used.  Because the transcutaneous pacemaker is set to 70 beats per minute, the femoral pulse should be palpated at 70 beats per minute as well.  Although asking the patient if the symptoms of “light-headedness” have resolved is not wrong, it is not a higher priority than checking the pulse.  Symptoms such as light-headedness may not improve for a period of time after pacing is initiated so it is more important to check for a palpable pulse than waiting for symptoms of poor perfusion to improve.  The presence of normal heart sounds is not as definitive for mechanical capture as palpation of the femoral pulse; therefore, palpating a femoral pulse carries a higher priority.   

Question Thirteen
The correct answer is C
Rationale: This strip indicates ventricular tachycardia.  If the patient has a pulse with ventricular tachycardia, cardioversion is appropriate.  The appropriate dose of electricity for wide complex tachycardia with a pulse is 100 Joules of energy via monophasic defibrillator.  Carotid massage is reserved for narrow complex regular tachycardia.  Because this patient is unstable, electrical therapy (as opposed to pharmacological therapy with Lidocaine) should be attempted initially.  Because this patient has a pulse, cardioversion as opposed to defibrillation should be attempted.  50 Joules of energy is also lower than the recommended dose of energy for ventricular tachycardia.

Question Fourteen
The correct answer is B
Rationale: Phentolamine (Regitine) helps to expedite absorption away from a site of extravasation.  In the case of a dopamine (Inotropin) extravasation, this will decrease the local vasoconstrictive effects and minimize secondary necrotic damage.  To be most effective, Phentolamine (Regitine) should be injected directly near the site of extravasation.  This may be accomplished by infusing the drug into the same intravenous catheter through which the extravasation occurred or through subcutaneous injection of the drug around the area of extravasation.  Phentolamine (Regitine) will not be effective if given topically, orally or intravenously.  

Question Fifteen
The correct answer is A
 
Rationale: Hypotension is commonly associated with right ventricular infarctions (secondary to parasympathetic stimulation and a decrease in left ventricular filling.)  Therefore, one goal of treatment for right sided infarctions is an increase in the patient’s blood pressure.  Patient’s with right ventricular infarctions are more likely to be bradycardic than tachycardic, therefore an elevation rather than decrease in the pulse rate is desirable.  There is little need to manipulate the temperature of a patient experiencing a right ventricular infarction, therefore, this is not a goal of treatment.  The respiratory rate of a patient experiencing a right ventricular infarction does not usually decrease, therefore a goal of treatment would not be to increase that rate. 

Question Sixteen
The correct answer is A
 
Rationale: Intermittent claudication, a symptom of an arterial occlusion is often described as a muscular cramp, ache or tightness in the affected extremity exacerbated by movement and quickly relieved with rest.  It does not have a circadian variation but is directly related to use of the limb.  It is not necessarily exacerbated by pressure to the area.  It is often a later rather than earlier finding of arterial occlusion. 

Question seventeen  
The correct answer is B

Rationale: In obstructive shock, blood is either obstructed from getting into or getting out of the heart.  Decreased filling of the heart will result in hypotension as well decreased cardiac output.  The hypotension associated with obstructive shock is more likely to cause pallor than flushed skin and the compensatory mechanisms of the body will cause a tachycardia rather than a bradycardia. 

Question eighteen
The correct answer is D
Rationale: Anectine (Succinylcholine) may cause muscle fasciculations.  Administration of Vecuronium (Norcuron) or Pancuronium (Pavulon) may decrease this effect.  Atropine may be given to children prior to intubation to reduce the risk of atropine but is not given to minimize the risk of fasciculations.  Lidocaine is sometimes given to reduce the gag or cough reflex and decrease arrhythmias prior to intubation, but will not reduce the risk of fasciculations.  Midazolam (Versed) is an induction agent and will not reduce the side effects of Anectine (Succinylcholine)  

Question nineteen
The correct answer is A
Rationale: A large pulmonary embolism, such as one that occludes the left pulmonary artery is likely to cause blood to back up into the right ventricle creating symptoms such as jugular venous distension.  Failure of blood to be able to move through the pulmonary bed will cause a decrease in blood return to the left ventricle resulting in hypotension rather than hypertension.  Splinter hemorrhages are associated with conditions such as endocarditis rather than pulmonary emboli.  Respiratory excursion may increase rather than decrease due to shortness of breath associated with a pulmonary embolism.  

Question twenty
Rationale:  A hemothorax is likely to cause signs of hypovolemic shock including: 
• Decreasing blood pressure

• Narrowing pulse pressure (as opposed to widening pulse pressure)  

A hemothorax is expected to cause increasing respiratory difficulties including:

• decreasing oxygen saturations

• increasing respiratory distress.  

A hemothorax is expected to cause findings such as:

• hyporesonance to percussion

• decreased fremitus over the area (as opposed to increased fremitus)

• egophony over the area  

A hemothorax is expected to cause a respiratory acidosis with:

• a declining serum pH • increasing serum carbon dioxide levels.

• (elevating serum bicarbonate and base excess levels are associated with a metabolic alkalosis)  

Hemoptysis is associated with bleeding directly into the lungs, a hemothorax is a collection of blood in the pleural space, therefore hemoptysis is not expected with a hemothorax. 

Question twenty-one
Rationale: Continuous bubbling in the water seal chamber indicates an air leak.  Actions which should be taken when there is a suspected air leak includes checking and re-enforcing connections and dressings.  The emergency nurse may consider clamping the chest tube but it would be best done near the drainage system rather than at the chest tube insertion site.  Clamping the chest tube should not be a higher priority than re-enforcing dressings at the chest tube insertion site.  Increasing the amount of suction or adding water to the water seal chamber are unlikely to stop an air leak. 

Question twenty-two
The correct answer is D
Rationale:  The typical manifestation of head wounds associated with intracranial injury is bradycardia accompanied by a full and bounding pulse secondary to the vasodilation of carbon dioxide accumulation, a wide pulse pressure, irregular respiratory patterns and frequently a mildly elevated temperature. 

Question twenty-three
The correct answer is A
Rationale:  Basilar skull fractures may be associated with increased intracranial pressure or injury to the cranial nerves including those which control the pupils.  Therefore, assessment of the pupils is an appropriate intervention for a patient with a suspected basilar skull fracture.  Because a basilar skull fracture may communicate with the nasal cavity, oxygen via nasal cannula should be avoided to prevent causing pneumocephalus.  Similarly, blowing the nose may force air through a basilar skull fracture causing a pneumocephalus.  No attempts should be made to stem the flow of cerebrospinal fluid from patients with a basilar skull fracture as this may contribute to an increased intracranial pressure. 

Question twenty four
The correct answer is A
Rationale: Cluster headaches are characterized by pain behind one of the eyes, sometimes described as a hot poker into the eye, that may radiate to the rest of the head.  It is usually unilateral.  A sensation of tightness is associated with tension headaches. 

Question twenty-five  
The correct answer is B
Rationale:  Patients with myasthenia gravis experience weakness with increased activity.  This weakness often starts with drooping of the eyelid or difficulty keeping the eyelid closed.  Edrophonium (Tensilon) will decrease symptoms of myasthenia gravis.  This drug should improve muscle strength, including hand grip strength.  It will not affect the color of the urine and does not have effects on blood pressure. 

Question twenty-six
The correct answer is C
Rationale: Intracranial injuries as well as cervical spinal injuries frequently occur with facial injuries.  Based on this patient’s mechanism of injury, the risk of cervical spinal injury is great and precautions should be initiated with airway, which precedes circulation (intravenous catheter) and wound care (application of ice and inspection for foreign bodies.) 

Question Twenty-Seven:
The correct answer is B
Rationale: The most common age for bacterial conjunctivitis is under the age of five years.  In fact, most cases occur in the neonate and are associated with a chlamydia infection that is transmitted to the infant at birth from the mother.  Facial cellulitis is more commonly associated with meningitis than conjunctivitis.  There is no seasonal variation to bacterial conjunctivitis nor do patients of Middle Eastern descent have a greater disposition to this illness. 
 

Question Twenty-Eight:  
The correct answer is B
Rationale: Cocaine hydrochloride is a vasoconstrictor.   Although it is being used topically in this situation, it can be absorbed through the nasal walls causing systemic hypertension.  Tinnitus, urinary retention and circumoral cyanosis are not commonly associated with the use of cocaine hydrochloride. 

 

Question Twenty-Nine:
The correct answer is A
Rationale:  A contusion is caused by the rupture of subcutaneous blood vessels resulting in the extravasation of blood into the tissue.  Although contusions can be large, the amount of blood is generally much less than a hematoma which is caused by the rupture of an artery or vein and generally involves significantly more bleeding.  In large spaces with greater dispensability, the amount of blood lost into a hematoma may result in hypovolemia (e.g. femur).  Hematomas can be deep in the tissue or may occur at the surface, therefore they are not defined by the depth.  Nearly any mechanism of injury can cause a hematoma or a contusion or both.  Hematomas and contusions can occur anywhere on the body; they are not defined by their location. 
 

Question Thirty:   
The correct answer is C
Rationale: If patients with pelvic trauma do not improve with aggressive fluid resuscitation and application of a pelvic binder, the likely cause of deterioration is arterial bleeding.  This can only be controlled by either angiogram with embolization or surgical intervention, therefore this is the most likely intervention at this point.  Insertion of a urinary catheter will not improve the patient’s hemodynamic status and introduction of a urinary catheter in the presence of significant pelvic trauma may be contra-indicated due to potential bladder or urethral trauma.  Placement of the pelvic binder over the greater trochanters and symphysis pubis is proper placement so reapplication is unlikely to change this patient’s condition.  The degree of hypotension and tachycardia in the second set of vital signs does not indicate that current strategies are effective, therefore continuing current interventions is unlikely to cause improvement in the patient’s condition. 

Question Thirty-One:
The correct answer is B
Rationale:  Uric acid, which tends to exacerbate gout, is more likely to precipitate into the joint spaces when it is colder.  Because of this, the patient of gout tends to increase during the night.  The symptoms of gout are not necessarily worse in the heat of summer or after excessive use of the affected limb.  Dairy products may actually help minimize the symptoms of gout rather than exacerbate them. 

Question Thirty-Two:
The correct answer is B
Rationale:  Patients with cholinergic toxicity, such as with pesticide exposure, can develop severe and rapid pulmonary edema.  This may be monitored partially through the assessment of adventitious lung sounds, such as pulmonary crackles.  Pain is not associated with this toxidrome, nor are changes in clotting studies or temperature. 
 

Question Thirty-Three:
The correct answer is A  
Rationale: Rationale:  Initial symptoms of iron overdoses include gastrointestinal symptoms due to the caustic nature of iron the gastrointestinal tract.  Shock, metabolic acidosis, and coagulopathies are more common 12 -24 hours post-ingestion, small bowel obstruction and liver problems are more likely to occur weeks or months following the ingestion, and tremor, slurred speech, and right sided weakness are not associated with iron overdoses. 

Question Thirty-Four:
The correct answer is A
Rationale: Patients who have ingested a chemical should be kept “nothing by mouth” until the type of chemical and the amount of damage can be ascertained.  The stomach is designed for extreme pHs but the throat and esophagus are not, therefore it is never desirable to encourage emesis.  Alkali substances can cause esophageal perforations; therefore, gastric tubes are not indicated.  Fluids can interact with acids causing steam and a secondary thermal burn and alkali substances can perforate the gastrointestinal tract, therefore, oral substances should not be given. 

Question Thirty-Five:
The correct answer is A  
Rationale: Hydroxocobalamin (Cyanokit) is known to cause reddish brown discoloration on the skin, mucous membranes and/or urine and the patient should be warned about this possible side effect.  Itchiness is not a normal reaction to the drug and the patient should seek medical care for a possible allergic reaction.  Alcohol and ringing in the ears are not associated with reactions to this drug, therefore these are not indications that the patient has understood the discharge instructions he or she has been given. 
 

Question Thirty-Six:
The correct answer is A
Rationale: Rationale: The toxins of coelenterates such as jellyfish, Portuguese man-of-war, hydrozoan fire corals, and sea wasps are best inactivated by applying isopropyl alcohol or vinegar.  There is not therapeutic advantage to wrapping the area in a compressive dressing.  Fresh water will actually stimulate the poison of these animals, therefore, they should only be cleansed with sea or salt water.  Coagulopathies do not occur shortly after a sting by a coelenterate, therefore, coagulation studies are not as appropriate as applying isopropyl alcohol. 

Question Thirty-Seven:  
The correct answer is B
Rationale:  Inactive tuberculosis is not communicable.  Patients who are symptomatic risk passing their disease on to others.  A tuberculosis skin test indicates exposure to the disease, but does not indicate whether the disease is active or has been successfully treated.  Inactive disease and disease that has been successfully treated will still have a positive skin test.  Patients who have developed a positive skin test may be treated for the disease. 
 

Question Thirty-Eight:  
The correct answer is A
Rationale: Albumin is important in maintaining osmolality and fluid balances in the body.  Decreased albumin causes fluid to leak into the extravascular compartment leading to edema.  Because albumin is produced by the liver, decreased albumin levels are frequently associated with liver failure.  Swelling of the liver causes portal hypertension and this hypertension, in addition to decreased serum osmolality causes fluid to leak into the abdomen causing ascites.  Liver insufficiency, which will cause ascites, is more likely to cause an elevated ammonia, Alanine transaminase (a liver enzyme) is likely to elevate with liver problems rather than decrease.  Ascites is not associated with an elevated white blood cell count. 

Question Thirty-Nine: 
The correct answer is B
Rationale: Rationale:  Symptoms of Crohn’s disease include cramping abdominal pain which often locates into the periumbilical region or the right lower quadrant (as opposed to the left lower quadrant).  Bloody diarrhea is most commonly associated with ulcerative colitis.  Crohn’s disease patients are more likely to have steatorrhea and may also develop intestinal obstructions.  Bruising around the umbilicus is indicative of retroperitoneal bleeding in conditions such as pancreatitis but is not associated with Crohn’s disease. 

Question Forty:
The correct answer is D
The area of the bowel that becomes strangulated in a strangulated inguinal hernia has compromised blood supply.  This can cause symptoms such as fever and erythema/redness of the skin over the hernia.  Anuria is not associated with a strangulated hernia.  Strangulated hernias cause bowel obstructions which is most likely to cause lack of bowel movements rather than bloody diarrhea.  A dull ache at the site of herniation is a normal finding in a non-strangulated hernia.  Those with strangulated hernias are more likely to experience sharp pain at the site of herniation. 
 

Question Forty-One:  
The correct answer is A
 Rationale: Patients with pancreatitis are unable to digest their fats appropriately and calcium may be attracted to fat, therefore patients with pancreatitis may end up with hypocalcemia.  One manifestation of hypocalcemia is tetany when a blood pressure cuff is applied.  This would be treated with calcium chloride.  Potassium chloride, magnesium sulfate and sodium bicarbonate will not elevate serum calcium. 

 

Question Forty-Two:  
The correct answer is B
 Rationale: Irritation of the area is known to increase the incidence of outbreaks in patients with genital herpes.  Wearing cotton rather than synthetic underwear may decrease irritation, thereby decreasing the incidence of outbreaks.  Open lesions associated with an outbreak should be kept dry.  Creams and lubricants should not be applied, both of which can increase healing time.  Although genital herpes infections cannot be cured, steroids are not used to control this infection.  (Anti-viral agents are more likely to be used).  Barrier protection should be used during intercourse when a patient has genital herpes, regardless of whether they have lesions or not.  Protection should not be discontinued one week after the lesions have healed.  

Question Forty-Three:   
The correct answer is A
Rationale:  Although this woman presents with signs of a ruptured ectopic pregnancy, her diagnosis is unimportant.  Pale, diaphoretic skin as well as tachycardia are all signs of potential oxygen debt and cardiovascular compromise and the highest intervention appropriate for these problems is the administration of oxygen.  Although initiation of an intravenous line is also important, this is considered a circulatory intervention and does not carry a higher priority than oxygen which is a breathing intervention.  A urine pregnancy test and type and cross match area also important interventions but do not carry a higher priority than administration of oxygen. 

Question Forty-Four:  
The correct answer is B
Rationale: Rationale:  Following birth, the uterus should feel firm, like a grapefruit and should be centrally aligned.  The uterus will be easily palpable for several days to weeks after birth before it descends back into the pelvis.  If the fundus is soft and boggy, it likely indicates the presence of clots or blood in the posterior section and this indicates the need to perform uterine massage.  If the uterus is not midline, it is indicative of a full bladder which may contribute to post-partum bleeding.