BCEN Patient Assessment and Diagnosis 3

Question 1

A pediatric patient presents with a barking cough, inspiratory stridor, and low-grade fever. The MOST likely diagnosis is:

Accepted Answer

Croup (laryngotracheobronchitis)

Answer

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?

Accepted Answer

Bradycardia, hypertension, and irregular respirations

Answer

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:

Accepted Answer

Acute decompensated heart failure

Answer

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?

Accepted Answer

Sudden severe pain radiating to the back with hypotension

Answer

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?

Accepted Answer

Prepare for definitive airway management

Answer

A GCS of 8 or less indicates inability to protect the airway, making definitive airway management the immediate priority.

(BCEN) Board of Certification of Emergency Nursing Practice Test