Ambulatory Care Test Ambulatory Care Patient Assessment and Triage 4 — Questions and Answers
Question 1: Which of the following is the MOST reliable early indicator of shock in an ambulatory patient?
- Decreased blood pressure below 90 systolic
- Tachycardia with cool, clammy skin and anxiety (Correct answer)
- Bradycardia with warm, flushed skin
- Normal vital signs with patient complaint of feeling 'off'
Correct answer: Tachycardia with cool, clammy skin and anxiety
Compensatory tachycardia with peripheral vasoconstriction (cool, clammy skin) and altered mentation are early signs of shock before hypotension develops.
Question 2: A patient calls the advice line reporting she took double her prescribed metformin dose by accident 2 hours ago. She is asymptomatic. What is the BEST triage response?
- Advise her to induce vomiting to eliminate the medication
- Direct her to the emergency department and monitor for signs of lactic acidosis (Correct answer)
- Reassure her that one missed dose error is harmless and continue the regular schedule
- Tell her to drink extra water and call back only if symptoms develop
Correct answer: Direct her to the emergency department and monitor for signs of lactic acidosis
Metformin overdose carries risk of lactic acidosis, a potentially life-threatening complication requiring emergency evaluation even if initially asymptomatic.
Question 3: The AIMS (Abnormal Involuntary Movement Scale) is used in ambulatory care to monitor patients for side effects of:
- Long-term NSAID use
- Antipsychotic medications (Correct answer)
- Antihypertensive therapy
- Anticoagulation treatment
Correct answer: Antipsychotic medications
The AIMS scale screens for tardive dyskinesia and other involuntary movement disorders associated with antipsychotic medications.
Question 4: A patient with a known peanut allergy reports tingling lips and throat tightness after eating at a restaurant 15 minutes ago. She has her EpiPen. The nurse should FIRST:
- Instruct her to take an oral antihistamine and observe for 1 hour
- Direct her to use her EpiPen immediately and call 911 (Correct answer)
- Have her come directly to the clinic for assessment
- Advise her to drink water and avoid the allergen in the future
Correct answer: Direct her to use her EpiPen immediately and call 911
Throat tightness indicates potential airway involvement in anaphylaxis; epinephrine is the first-line treatment and 911 must be called.
Question 5: When performing a mental status examination in the ambulatory setting, which component assesses whether the patient knows today's date, their location, and who they are?
- Affect
- Orientation (Correct answer)
- Insight
- Judgment
Correct answer: Orientation
Orientation tests awareness of person, place, and time, which are foundational components of cognitive functioning.
Question 6: A 55-year-old male presents for annual wellness. He reports drinking 4-5 alcoholic drinks daily. The nurse should use which validated tool to further assess alcohol use?
- PHQ-9
- AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) (Correct answer)
- GAD-7
- CAGE-AID
Correct answer: AUDIT-C (Alcohol Use Disorders Identification Test-Consumption)
The AUDIT-C is a validated, concise screening tool recommended for identifying hazardous alcohol use in primary care settings.
Question 7: A patient being discharged after a same-day procedure reports pain of 8/10 despite receiving the prescribed analgesic. The PRIORITY nursing action is:
- Document the pain score and discharge the patient per protocol
- Reassess the patient, notify the provider, and delay discharge until pain is adequately controlled (Correct answer)
- Advise the patient to take additional over-the-counter pain medication at home
- Provide distraction techniques and reassure the patient that pain is expected post-procedure
Correct answer: Reassess the patient, notify the provider, and delay discharge until pain is adequately controlled
Uncontrolled pain prior to discharge is unsafe; the nurse must reassess, communicate findings to the provider, and ensure adequate pain management before release.
Ambulatory Care Test Ambulatory Care Patient Assessment and Triage 4
Which of the following is the MOST reliable early indicator of shock in an ambulatory patient?