Ambulatory Care Test Ambulatory Care Patient Assessment and Triage 2 — Questions and Answers
Question 1: A patient calls reporting sudden onset of severe chest pain radiating to the left arm with diaphoresis. What is the MOST appropriate triage action?
- Schedule an urgent same-day appointment
- Instruct the patient to call 911 immediately (Correct answer)
- Advise rest and call back if symptoms worsen
- Recommend over-the-counter antacids and monitor
Correct answer: Instruct the patient to call 911 immediately
Chest pain with radiation to the left arm and diaphoresis are classic signs of a myocardial infarction requiring emergency services.
Question 2: During a telephone triage call, a parent reports their 2-year-old ingested an unknown household chemical 10 minutes ago. What is the FIRST action?
- Ask the parent to induce vomiting immediately
- Direct the parent to call Poison Control (1-800-222-1222) (Correct answer)
- Schedule an urgent appointment within 2 hours
- Advise the parent to give the child milk to dilute the substance
Correct answer: Direct the parent to call Poison Control (1-800-222-1222)
Poison Control provides expert, substance-specific guidance and should be contacted immediately in any ingestion case.
Question 3: Which pain scale is MOST appropriate when assessing pain in a non-verbal pediatric patient aged 2 years?
- Numeric Rating Scale (NRS) 0-10
- Visual Analog Scale (VAS)
- FLACC Scale (Face, Legs, Activity, Cry, Consolability) (Correct answer)
- McGill Pain Questionnaire
Correct answer: FLACC Scale (Face, Legs, Activity, Cry, Consolability)
The FLACC scale uses behavioral observations making it ideal for non-verbal or preverbal children.
Question 4: A patient presents with a blood pressure of 180/110 mmHg and reports a headache but no other symptoms. Per JNC guidelines, this is classified as:
- Hypertensive emergency requiring immediate IV therapy
- Hypertensive urgency requiring oral medication adjustment (Correct answer)
- Normal variation requiring no intervention today
- Stage 1 hypertension requiring lifestyle counseling only
Correct answer: Hypertensive urgency requiring oral medication adjustment
Hypertensive urgency involves severely elevated BP without evidence of end-organ damage, managed with oral medications.
Question 5: A nurse is triaging patients in a busy ambulatory clinic. Which patient should be seen FIRST?
- A 45-year-old with a 3-day history of low back pain rated 5/10
- A 60-year-old with new onset confusion and slurred speech (Correct answer)
- A 30-year-old requesting a prescription refill for a maintenance medication
- A 25-year-old with a mild sore throat and low-grade fever for 2 days
Correct answer: A 60-year-old with new onset confusion and slurred speech
New onset confusion and slurred speech are signs of a possible stroke and require immediate assessment.
Question 6: When collecting a chief complaint during patient intake, the nurse should document it:
- Using medical terminology to ensure accuracy in the chart
- In the patient's own words using quotation marks (Correct answer)
- As interpreted by the nurse for clinical clarity
- With the nurse's preliminary diagnosis added for context
Correct answer: In the patient's own words using quotation marks
Documenting the chief complaint in the patient's own words preserves accuracy and provides a baseline for clinical comparison.
Question 7: A patient reports taking ibuprofen 800mg three times daily for the past 2 weeks without relief of knee pain. The MOST important assessment priority is:
- Evaluating for NSAID-related gastrointestinal or renal complications (Correct answer)
- Recommending a higher dose for better analgesic effect
- Switching the patient to acetaminophen without further assessment
- Ordering physical therapy without additional evaluation
Correct answer: Evaluating for NSAID-related gastrointestinal or renal complications
Prolonged high-dose NSAID use increases risk of GI bleeding, peptic ulcers, and renal impairment requiring evaluation.
Ambulatory Care Test Ambulatory Care Patient Assessment and Triage 2
A patient calls reporting sudden onset of severe chest pain radiating to the left arm with diaphoresis.
What is the MOST appropriate triage action?