BCEN Patient Assessment and Diagnosis 3 — Questions and Answers
Question 1: A pediatric patient presents with a barking cough, inspiratory stridor, and low-grade fever. The MOST likely diagnosis is:
- Epiglottitis
- Croup (laryngotracheobronchitis) (Correct answer)
- Foreign body aspiration
- Bacterial tracheitis
Correct answer: Croup (laryngotracheobronchitis)
A barking 'seal-like' cough, stridor, and low-grade fever in a toddler are hallmark findings of viral croup.
Question 2: Which assessment finding is MOST indicative of increased intracranial pressure in an adult?
- Heart rate 110 bpm, BP 90/60 mmHg
- Bradycardia, hypertension, and irregular respirations (Correct answer)
- Tachycardia, hypotension, and diaphoresis
- Tachypnea, normotension, and agitation
Correct answer: Bradycardia, hypertension, and irregular respirations
Cushing's triad — bradycardia, hypertension, and irregular respirations — is a late and ominous sign of rising ICP.
Question 3: A patient presents with inspiratory crackles, JVD, S3 gallop, and bilateral pitting edema. These findings are MOST consistent with:
- Pneumonia
- Pulmonary embolism
- Acute decompensated heart failure (Correct answer)
- Cardiac tamponade
Correct answer: Acute decompensated heart failure
Crackles, JVD, an S3 gallop, and bilateral edema together indicate acute decompensated heart failure with volume overload.
Question 4: During assessment of an abdominal aortic aneurysm (AAA), the nurse palpates a pulsatile midline mass. Which associated finding would suggest rupture?
- Mild periumbilical tenderness
- Sudden severe pain radiating to the back with hypotension (Correct answer)
- Intermittent claudication
- Hematuria
Correct answer: Sudden severe pain radiating to the back with hypotension
Sudden severe abdominal or back pain with hemodynamic instability in a patient with a known AAA strongly suggests rupture.
Question 5: A trauma patient is GCS 8. What is the PRIORITY nursing action?
- Obtain a CT scan of the head
- Prepare for definitive airway management (Correct answer)
- Place a Foley catheter
- Start two large-bore IVs
Correct answer: Prepare for definitive airway management
A GCS of 8 or less indicates inability to protect the airway, making definitive airway management the immediate priority.
Question 6: When assessing a burn patient, which formula is used to estimate the percentage of total body surface area (TBSA) burned in adults?
- Parkland formula
- Rule of Nines (Correct answer)
- Broselow tape
- Galveston formula
Correct answer: Rule of Nines
The Rule of Nines divides the adult body into regions each representing 9% (or multiples of 9%) to estimate TBSA burned.
Question 7: A patient with diabetes presents with Kussmaul respirations, fruity breath odor, and altered mental status. The nurse should anticipate which diagnosis?
- Hyperosmolar hyperglycemic state (HHS)
- Diabetic ketoacidosis (DKA) (Correct answer)
- Hypoglycemia
- Lactic acidosis
Correct answer: Diabetic ketoacidosis (DKA)
Kussmaul respirations (deep, rapid) and fruity breath from acetone are compensatory signs of metabolic acidosis in DKA.
BCEN Patient Assessment and Diagnosis 3
A pediatric patient presents with a barking cough, inspiratory stridor, and low-grade fever.
The MOST likely diagnosis is: