BCEN Emergency Assessment 2

Question 1

When performing a secondary assessment on a trauma patient, which mnemonic guides a head-to-toe evaluation?

Accepted Answer

DCAP-BTLS

Answer

DCAP-BTLS (Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, Swelling) guides systematic head-to-toe trauma assessment.

Question 2

A patient presents with unequal pupils after head trauma. The left pupil is 6mm and non-reactive; the right is 3mm and reactive. What does this finding suggest?

Accepted Answer

Ipsilateral uncal herniation on the left side

Answer

A unilaterally dilated, non-reactive pupil after head trauma indicates uncal herniation with compression of cranial nerve III on the same side.

Question 3

During triage of a mass casualty incident, a patient is breathing only after repositioning the airway and has a respiratory rate of 28. Under START triage, this patient is categorized as:

Accepted Answer

Red (immediate)

Answer

Under START triage, a patient who breathes only after airway repositioning is categorized red (immediate) regardless of respiratory rate.

Question 4

When assessing capillary refill time in an adult, which finding is considered abnormal?

Accepted Answer

Greater than 2 seconds

Answer

Capillary refill time greater than 2 seconds in adults indicates impaired peripheral perfusion and may suggest shock or vascular compromise.

Question 5

A patient with chest pain rates their pain 8/10 and describes it as crushing, radiating to the left arm, with diaphoresis. Which initial assessment action is highest priority?

Accepted Answer

Obtain a 12-lead ECG

Answer

A 12-lead ECG should be obtained within 10 minutes of arrival for suspected ACS to identify ST-elevation and guide reperfusion therapy.

(BCEN) Board of Certification of Emergency Nursing Practice Test

(BCEN) Board of Certification of Emergency Nursing Practice Test

BCEN Emergency Assessment 2