AACN PCCN NOV 2023 Exam Hanbook version 1.1.1 Exam Questions

Correct answer: Care-based

The care-based framework, also known as the ethics of care, focuses on the importance of relationships and the responsibilities that arise from them. It emphasizes empathy, compassion, and the nurturing of interpersonal connections, seeking to protect and maintain relationships that might be at risk in a given situation. This approach is concerned with the context of moral decisions and the well-being of all parties involved, particularly in preserving the integrity of relationships.

The utilitarian framework is concerned with the outcomes of actions, aiming to maximize overall happiness or minimize overall suffering. It evaluates actions based on their consequences rather than the relationships involved.

The principle-based framework relies on fundamental ethical principles such as autonomy, justice, beneficence, and nonmaleficence. It provides a structured approach to ethical decision-making based on adherence to these principles, without a primary focus on relationships.

The duty-based framework, also known as deontological ethics, emphasizes following moral rules or duties. It focuses on the inherent rightness or wrongness of actions themselves rather than their consequences or the relationships they impact.

Correct answer: Initiate fluid resuscitation and obtain an urgent CT angiogram

The patient’s hypotension and tachycardia suggest hypovolemic shock secondary to ischemic bowel. The absent bowel sounds are a key finding that indicates the severity of the ischemia. Immediate fluid resuscitation is critical to stabilize this patient, and a CT angiogram is necessary to confirm the diagnosis and guide further treatment.

Opioid analgesia is important for pain management but does not address the underlying ischemia or hypotension, which should be prioritized. Proton pump inhibitors are used for gastric ulcers but are inappropriate for ischemic bowel in this case. A nasogastric tube may be used later for gastric decompression but is not the initial life-saving intervention.

Correct answer: Hypoglycemia and hypomagnesemia

Hypoglycemia and hypomagnesemia are commonly associated with liver failure. The liver plays a crucial role in glucose regulation, and impaired liver function can lead to decreased glycogen storage and gluconeogenesis, resulting in hypoglycemia. Additionally, liver failure can cause electrolyte imbalances, including hypomagnesemia, due to poor dietary intake, malabsorption, and increased renal losses.

Hypermagnesemia is not typically seen in liver failure; it is more commonly associated with renal insufficiency or excessive magnesium intake.

Hypokalemia and hyperglycemia are not the primary electrolyte imbalances associated with liver failure. Hyperglycemia is more commonly related to conditions such as diabetes mellitus.

Hyperkalemia and hypocalcemia can occur in various other conditions but are not the hallmark electrolyte imbalances of liver failure.

Correct answer: At least six hours

For coronary angiography and other procedures requiring sedation, patients are typically advised to be NPO (nothing by mouth) for at least six hours to reduce the risk of aspiration during the procedure. Given the urgency of the situation, if the patient has not been NPO for the recommended duration, the medical team must weigh the risks and benefits of proceeding immediately versus waiting for the appropriate NPO period. In this scenario, the patient’s recent intake of a snack and medication must be considered, but the standard recommendation remains a minimum of six hours NPO.

Correct answer: Direct contact with contaminated surfaces

VRE is most commonly transmitted through direct contact with contaminated surfaces or the hands of healthcare workers. Proper hand hygiene and surface disinfection are essential to preventing the spread of this organism.

Airborne transmission is associated with infections like tuberculosis, not VRE. Ingestion of contaminated food is a possible route for some infections but not typically for VRE in a healthcare setting. Inhalation of respiratory droplets is a common mode of transmission for respiratory viruses but not for VRE.

Correct answer: Ascending

An aneurysm located between the aortic valve and the innominate artery is classified as an ascending aortic aneurysm. This section of the aorta is the first part that emerges from the heart, specifically from the left ventricle, and extends up to the point where the aorta begins to arch (the aortic arch). The innominate artery (also known as the brachiocephalic artery) branches off from the aortic arch, which marks the end of the ascending aorta.

Transverse aortic aneurysms are less common and typically involve the aortic arch. Descending aortic aneurysms occur after the aortic arch and extend down the thoracic aorta. Thoracoabdominal aneurysms involve both the thoracic and abdominal portions of the aorta.

Correct answer: pH, ventilation, and oxygenation

ABG monitoring may be used to assess acid-base balance (pH), ventilation, and oxygenation. It is a test that measures the amount of oxygen and carbon dioxide in the blood and checks the acidity of the blood (called the acid-base balance, or pH level) using a blood gas analyzer. From these measurements, other parameters are calculated, including oxygen saturation, base excess, and bicarbonate. The blood sample is obtained via direct puncture of an artery (typically the radial artery) or by withdrawing blood through an indwelling arterial catheter system.

Correct answer: Urine output of less than 400 mL/day

Oliguria is defined as a urine output of less than 400 mL/day in adults. This level of output is significantly below normal and can indicate kidney dysfunction, dehydration, or other serious medical conditions requiring prompt evaluation and treatment.

A urine output of less than 1,000 mL/day is below normal but is not the threshold for oliguria; it might indicate reduced renal function but not to the level defined as oliguria.

A urine output of less than 2,000 mL/day is within the normal range for adults and would not be considered oliguria.

A urine output of less than 100 mL/day would be considered anuria, which is the absence or near absence of urine production, indicating more severe renal failure than oliguria.

Correct answer: Hepatic encephalopathy

Hepatic encephalopathy is associated with liver dysfunction, and common clinical findings include confusion, jaundice, and disorientation. The buildup of toxins, particularly ammonia, is a hallmark of this condition.

Hypoxic-ischemic encephalopathy results from oxygen deprivation of the brain and typically follows cardiac arrest, severe hypotension, or drowning, which is not noted in this scenario. Infectious encephalopathy is caused by infections such as viral encephalitis. This patient does not show signs of fever, neck stiffness, or headache, making infection less likely. Metabolic encephalopathy, often seen in conditions like diabetes or renal failure, presents with similar confusion but is typically accompanied by metabolic disturbances such as hyperglycemia or uremia.

Correct answer: Acute pancreatitis

The Bedside Index for Severity in Acute Pancreatitis (BISAP) is a simple scoring system used to assess the severity of acute pancreatitis. This score allows for early identification of patients at a higher risk of in-hospital mortality, and it is usually performed at hospital admission. Each variable provides one point; the higher the score, the greater the risk of mortality. 

Five variables measured within the first 24 hours were found to be predictive of in-hospital mortality:

• Blood urea nitrogen (BUN) >25 mg/dl
• Impaired mental status
• Presence of two or more criteria of Systemic Inflammatory Response Syndrome (SIRS)
• Age >60 years
• Presence of a pleural effusion on imaging

BISAP scoring is not used to assess a patient with pneumonia, liver failure, or alcoholic liver disease.

Correct answer: Level of consciousness

The single most important indicator of cerebral functioning is the level of consciousness. This is often assessed using tools such as the Glasgow Coma Scale (GCS) to provide a standardized measure of a patient's consciousness and neurological status. Changes in the level of consciousness can be an early sign of neurological deterioration and are critical in evaluating cerebral function.

Certain medications can affect pupil size, and some patients have unequal or nonreactive pupils normally. A complete cranial nerve assessment is rarely warranted. A patient may have unequal motor strength due to factors unrelated to their current condition.

Correct answer: Decreased peripheral pulses, decreased urinary output, decreased oxygen saturation

Acute heart failure related to pericardial effusion can result in decreased cardiac output. This decreased output can lead to reduced perfusion to peripheral tissues, which manifests as decreased peripheral pulses and decreased urinary output due to decreased renal perfusion. Decreased oxygen saturation can occur as a result of impaired cardiac function and poor oxygen delivery to tissues.

Hypertension is not typically associated with pericardial effusion leading to acute heart failure. Instead, hypotension is more likely due to decreased cardiac output. Tachycardia and increased respiratory rate may occur in response to decreased cardiac output and hypoxia. With reduced cardiac output and renal perfusion, urinary output would typically decrease, not increase. In acute heart failure, the respiratory rate usually increases (tachypnea) due to hypoxia and the body's attempt to compensate for reduced oxygenation.

Correct answer: An overdistended bladder

Autonomic dysreflexia is a condition commonly seen in individuals with spinal cord injuries, particularly those at or above the T6 level. It is most often triggered by noxious or painful stimuli below the level of the spinal cord injury. One of the most common triggers is an overextended bladder, which can result from urinary retention or a blocked catheter. This condition leads to an exaggerated sympathetic nervous system response, causing severe hypertension, bradycardia, headache, and other symptoms.

While exposure to cold temperatures, high blood pressure, and low blood sugar can affect overall health, they are not the primary triggers of autonomic dysreflexia.

Correct answer: Valves on the right side of the heart are more commonly affected

Valvular heart disease more commonly affects the valves on the left side of the heart, specifically the mitral and aortic valves. These valves are under higher pressure than the right-sided valves (tricuspid and pulmonary valves), making them more susceptible to conditions such as stenosis or regurgitation.

A normally functioning valve should open fully, allowing free blood flow with no pressure difference between the upstream and downstream chambers or vessels. A stenotic valve does not open fully, causing a narrowed opening that impedes blood flow. An insufficient or regurgitant valve fails to close completely, allowing blood to flow backward, a condition known as regurgitation.

Correct answer: Aspirin

Administering aspirin is the most appropriate method of managing unstable angina in the emergency department. Aspirin inhibits platelet aggregation, reducing the risk of clot formation and helping to improve blood flow in the coronary arteries.

Administering a diuretic may be appropriate for managing fluid overload or heart failure but is not a primary treatment for unstable angina.

An antibiotic would be indicated for an infection, not for the management of unstable angina.

Performing a chest X-ray can help rule out other causes of chest pain, such as pneumothorax or pneumonia, but it does not directly treat unstable angina.

Correct answer: Eye opening, motor response, verbal response

The GCS is often used to monitor neurologic status in patients with traumatic brain injuries because it provides a standardized approach to assessing and documenting a patient's level of consciousness. Patient response is determined by verbal and motor responses and eye opening. 

Each response is scored and results are added; scores range from 3 to 15, and a high score of 15 indicates a fully alert and oriented patient who can follow commands.

Respiratory response and pupil reactivity are not categories of the GCS.

Correct answer: Chronic Obstructive Pulmonary Disease (COPD)

Respiratory acidosis occurs when carbon dioxide (CO₂) accumulates in the blood due to impaired ventilation or inadequate gas exchange. COPD impairs the lungs' ability to effectively expel CO₂, leading to its buildup in the bloodstream and resulting in respiratory acidosis.

Neurogenic hyperventilation occurs when there is an abnormally high rate and depth of breathing due to injury or dysfunction in the brainstem. This leads to excessive expulsion of CO₂ from the body, causing a decrease in CO₂ levels in the blood (hypocapnia), which results in respiratory alkalosis, not acidosis.

When a patient is on a ventilator with settings that cause hyperventilation (e.g., too high a respiratory rate or tidal volume), they can "blow off" too much CO₂, decreasing CO₂ levels in the blood. This results in respiratory alkalosis rather than respiratory acidosis.

Hypokalemia primarily affects muscle function and can contribute to metabolic alkalosis rather than respiratory acidosis. 

Correct answer: Hypotension due to cardiogenic shock

The patient's ST-segment elevation in the anterior leads, along with hypotension, suggests a large myocardial infarction affecting the left ventricle. This can lead to cardiogenic shock, a condition in which the heart cannot pump effectively, resulting in low blood pressure.

Bradycardia due to AV block is less likely in this case, as the patient is not bradycardic (heart rate is 90 beats per minute). Pulmonary embolism is not suggested by the ECG findings or clinical presentation in this case. Atrial fibrillation may occur with myocardial ischemia, but there is no indication of arrhythmias in this patient’s presentation.

Correct answer: High-dose IV proton pump inhibitor therapy in conjunction with therapeutic endoscopy

High-dose Intravenous (IV) Proton Pump Inhibitor (PPI) therapy is considered the most cost-effective and evidence-based approach to managing hospitalized patients with acute peptic ulcer bleeding. Proton pump inhibitors reduce gastric acid secretion, stabilize blood clots on ulcer surfaces, and prevent rebleeding. When combined with therapeutic endoscopy, which allows direct treatment of the bleeding site, this approach has been shown to be highly effective in controlling bleeding and reducing the need for surgery or additional interventions, making it cost-effective.

While vasopressin can be used for bleeding control, it is less commonly employed due to its systemic vasoconstrictive effects, which can cause significant side effects, including myocardial ischemia. 

H2 antagonists, like ranitidine, have been largely replaced by PPIs in the management of acute peptic ulcer bleeding due to their inferior ability to reduce acid secretion and stabilize clots. 

Octreotide, a somatostatin analog, is often used for variceal bleeding rather than peptic ulcer bleeding. It can reduce portal blood flow and pressure, but it is not the first-line treatment for peptic ulcer bleeding.

Correct answer: The patient's cultural and religious beliefs about healthcare interventions

Understanding the patient's cultural and spiritual context is key to providing culturally competent care and supporting his autonomy.

Assessing the patient’s understanding of dialysis consequences is important but secondary to understanding his beliefs, which may shape how he processes medical information. Family involvement is also critical, but it may not be appropriately guided without first understanding the patient’s beliefs. Focusing only on vital signs overlooks the importance of cultural and spiritual beliefs in the patient’s decision-making process.