BCEN Patient Assessment and Diagnosis 4

Question 1

A patient presents with unilateral absence of breath sounds after a central line placement. The nurse should first assess for:

Accepted Answer

Pneumothorax

Answer

Absent unilateral breath sounds following central line insertion is a classic presentation of iatrogenic pneumothorax.

Question 2

Which assessment finding differentiates neurogenic shock from hypovolemic shock?

Accepted Answer

Hypotension with bradycardia and warm skin

Answer

Neurogenic shock presents with hypotension and bradycardia (loss of sympathetic tone) with warm, dry skin, unlike the cold, clammy presentation of hypovolemic shock.

Question 3

A 3-year-old presents with drooling, muffled voice, high fever, and refusal to move the neck. The nurse should FIRST:

Accepted Answer

Prepare for immediate airway management and notify the physician

Answer

These signs suggest epiglottitis — a life-threatening airway emergency; the airway must be secured immediately without agitating the child.

Question 4

Which pain assessment tool is MOST appropriate for a non-verbal adult patient with cognitive impairment?

Accepted Answer

PAINAD (Pain Assessment in Advanced Dementia)

Answer

PAINAD assesses breathing, vocalization, facial expression, body language, and consolability in non-verbal dementia patients.

Question 5

A patient presents with unequal pupils after a head injury. The left pupil is 7 mm and non-reactive. This finding suggests:

Accepted Answer

Uncal herniation compressing CN III on the left

Answer

A fixed, dilated pupil after head trauma indicates uncal herniation compressing the ipsilateral oculomotor nerve (CN III).

(BCEN) Board of Certification of Emergency Nursing Practice Test

(BCEN) Board of Certification of Emergency Nursing Practice Test

BCEN Patient Assessment and Diagnosis 4