BCEN CPEN Exam Questions

Correct answer: Preschoolers

In the preschool group (ages 3-5 years), death is often viewed as reversible or temporary. Preschoolers may say that someone is "dead" without any understanding of the finality of death. Preschoolers may fear death as a separation from someone they love or a primary caregiver, being hurt or injured, or even a punishment for misbehavior(s).

Correct answer: Iodine or shellfish

Cardiac catheterization is an invasive procedure that can be used to diagnose a congenital heart defect, as well as repair certain congenital heart defects. It can also help identify rejection in a transplanted heart, aid in the diagnosis of infectious etiology or continued inflammatory response in myocarditis (both via a biopsy), and assess for cellular disease such as mitochondrial disease.

A catheter is inserted into the femoral artery and then threaded into the heart. Prior to the procedure, it is important to assess for any allergies to iodine or shellfish. An allergy to either of these increases the risk of an allergic reaction to the contrast dye used in the procedure.

Correct answer: Inotropic agents may be indicated in cases of septic shock 

Inotropic agents are primarily used in the setting of shock. These agents increase the contraction force of the myocardium and may cause peripheral vasoconstriction or vasodilation, depending on the medication. Dopamine is used for most types of shock and has variable dose-dependent effects. 

Dobutamine is not ideal in a hypotensive patient due to decreased systemic vascular resistance (SVR) and blood pressure, but it may be ideal for a normotensive child in cardiogenic shock. Milirone may cause hypotension and vasodilation, which requires monitoring that is typically done via an arterial line. Fluid resuscitation should be initiated before and during the use of inotropic agents.

Correct answer: Ataxic respirations

This breathing pattern is abnormal and refers to a complete irregularity of breathing, consisting of both deep and shallow breaths with irregular pauses and increasing periods of apnea. It is due to damage to the medulla oblongata from trauma or strokes.

Cheyne-Stokes respirations are described as periodic breathing with phases of hyperpnea alternating with apnea. It is often associated with Cushing's triad, indicating increasing intracranial pressure (ICP).

Central neurogenic hyperventilation is a sustained, rapid, and deep pattern of hyperpnea. It is unclear which mechanism in the brain causes this type of breathing.

Apneustic respirations are characterized by a prolonged inspiration with a pause at full inspiration lasting 2 to 3 seconds. They suggest damage to the brainstem near the level of the fifth cranial nerve nucleus.

Correct answer: "What is your understanding of the situation?"

The nurse can best approach this situation by asking open-ended questions to facilitate communication through clinical judgment, which is one of the eight nurse competencies as outlined in the Synergy Model for Patient Care. Clinical judgment involves reasoning and critical thinking skills.

Asking, "What is the best way I can help you?" and "What questions can I answer for you" are also open-ended questions but do not allow the nurse to assess the needs of the parents, nor do they allow the nurse to individualize information and fill in gaps in knowledge deficits. Asking if the parents understand the disease process elicits a simple yes or no answer, which does not give the nurse a thorough assessment of the parents' understanding.

Correct answer: Acute spasmodic laryngitis

Acute spasmodic laryngitis is distinct from laryngitis and LTB. It is characterized by recurrent paroxysmal attacks of laryngeal obstruction that happen specifically at night. The child feels well the following day. This condition is viral, and some children may be predisposed to it; allergies or hypersensitivities may be implicated in some cases. Management is the same as for infectious croup.

Acute epiglottitis and acute bacterial tracheitis are both caused by bacterial infections. Croup, or acute laryngotracheobronchitis, is viral but is not associated with allergies or hypersensitivity.

Correct answer: Sepsis

A perforated appendix is a common cause of peritonitis (inflammation of the serous membrane lining the abdominal cavity and covering the viscera), as the inflammatory response causes the exudation of fluid from the appendix into the peritoneal cavity. Sepsis is the most serious complication and a major cause of death from peritonitis.

Other complications include hypovolemia, abscess formation, and shock resulting from hypovolemia or septicemia.

Correct answer: Acute laryngotracheobronchitis (LTB)

Acute LTB is an inflammatory swelling of the submucosa in the subglottic area. Croup is a general term that refers to this inflammatory process, which results in stridor, coughing, and hoarseness. LTB primarily affects children younger than five years of age and peaks between nine and 18 months of age. It is gradual in onset, can be either viral or bacterial in origin, and is usually preceded by an upper respiratory infection. Viral LTB accounts for 85% of reported cases.

A barking cough is not present in any of the other options. Acute epiglottitis presents with acute onset of a high fever, dysphagia and drooling, respiratory distress, and inspiratory stridor. It primarily affects children ages two to five years old. Acute bacterial tracheitis presents with a high fever, inspiratory stridor, and drooling and can mimic epiglottitis. It generally occurs in children between two and four years old. Acute spasmodic laryngitis is characterized by recurrent paroxysmal attacks of laryngeal obstruction that occur chiefly at night, and the child feels well the next day. Allergies or hypersensitivities may be implicated, and affected patients range from one to three years old.

Correct answer: A generalized seizure

Generalized seizures (convulsive or nonconvulsive) originate in the cortical or subcortical areas of the brain and quickly spread bilaterally, affecting both sides of the brain. Generalized seizures include:

• absence seizures
• myoclonic seizures
• clonic seizures
• tonic seizures
• atonic seizures

Focal seizures start in one part of the brain and either stay local or can spread to other areas of the brain. Status epilepticus is defined as a prolonged seizure (usually 30 minutes or longer) or multiple consecutive seizures without regaining consciousness. A febrile seizure occurs in the setting of a fever.

Correct answer: Dilating the bronchioles

Beta-adrenergic agonists, such as albuterol, are considered essential bronchodilator drugs in the treatment of acute asthma exacerbations and for the prevention of exercise-induced bronchospasm (EIB). They work by binding with the beta receptors on the smooth muscle of the airways, allowing the smooth muscle to relax and resulting in easier breathing.

Corticosteroids are anti-inflammatory drugs used as first-line treatment to reverse airflow obstruction, control symptoms, and reduce bronchial hyperresponsiveness in chronic asthma. Anticholinergics may also be used for the relief of acute bronchospasm; they are helpful in acute, severe asthma when used in conjunction with beta-agonists and also reduce the amount of mucus produced by the airways. Leukotriene modifiers work by blocking inflammatory and bronchospasm effects; these are used for long-term asthma control.

Correct answer: PaCO₂ 62 mm Hg

Children with major intrathoracic injuries require ABG monitoring to evaluate for hypoxia, hypercarbia, and respiratory acidosis. Acute respiratory failure is evidenced by compromised breathing (i.e., not effectively breathing in oxygen and breathing out carbon dioxide) and increased carbon dioxide in the patient's blood (hypercarbia), leading to respiratory acidosis (as the patient holds onto carbon dioxide from ineffective breathing). Thus, a PaCO₂ over 45 (normal PaCO₂ is 35-45 mm Hg) and a pH below 7.35 (normal pH is 7.35-7.45) indicate an acidic state with a respiratory component.

This patient is in acute respiratory failure with a high PaCO₂ level (above 45 mm Hg) and a low pH. Therefore, the correct answer would be a PaCO₂ of 62 (too high, indicating acidosis) because the pH is within normal limits. A PaO₂ of 80 is normal. While 90% SaO₂ is not quite within normal limits (92% and above on room air is normal), it does not reflect ARF.

Correct answer: Growth failure

A VSD is a hole in the septum (wall) that separates the heart's lower chambers. This defect results from imperfect embryologic formation of the septal wall and occurs when the wall between the ventricles (lower chambers) does not develop fully in utero. VSDs account for up to 20% of congenital heart defects (CHD) and are the most common CHD, excluding a bicuspid aortic valve.

Infants are usually asymptomatic until 2 to 4 weeks of age, when pulmonary vascular resistance (PVR) falls, allowing shunting from the LV to the RV and creating pulmonary overcirculation. While some defects close spontaneously, the rest will need to be surgically repaired. Indications for intervention include congestive heart failure (CHF), pulmonary artery hypertension, growth failure, or evidence of left ventricular overload. Children with VSDs have increased metabolic demands and are at risk of failure to thrive.

Correct answer: Intubating the right mainstream bronchus

The most common complication of endotracheal intubation is inadvertent intubation of the right mainstem bronchus (if the tube is placed too deep) or dislodgment of the endotracheal tube (ETT) into the right mainstream bronchus if the child is positioned for procedures or transported within the facility. When this situation arises, chest expansion may not be equal, and breath sounds are absent or diminished on the left side of the chest. Pulse oximetry readings may be low, and ventilation may be difficult.

Prompt recognition of this complication is essential; it is corrected by withdrawing the ETT until equal breath sounds and equal chest movement are observed. Nurses must document ETT placement measurements at the nose or lip once intubation is established.

Correct answer: Exudate on tonsils

Acute epiglottitis is a severe, life-threatening condition requiring immediate medical attention. It primarily affects children ages two to five years but can occur from infancy to adulthood; it is characterized by a rapidly progressing bacterial infection of the epiglottis and surrounding area. The patient's history usually reveals an acute onset of symptoms, including a high fever, a sore throat and difficulty swallowing, dyspnea, and rapidly progressing respiratory obstruction from swelling tissue. The obstruction is supraglottic as opposed to subglottic (as seen in laryngitis). Stridor is a late finding and suggests near-complete airway obstruction.

Exudate on tonsils is not a clinical finding associated with epiglottitis.

Correct answer: Collaboration

The AACN Synergy Model for Patient Care was initially developed to serve as the foundation for certifying critical care nursing practice. Nurse competencies are driven by the needs of patients and families and reflect the integration of nursing knowledge, skills, and experiences that are required to meet the needs of patients and families and optimize their outcomes.

Competencies include clinical judgment, caring practices, advocacy/moral agency, collaboration, systems thinking, response to diversity, clinical inquiry, and facilitating learning.

Non-maleficence, autonomy, and justice are some of the ethical principles that guide nursing practice, along with optimizing patient care and outcomes.

Correct answer: Intravenous immune serum globulin (IVIG)

SCID is a rare genetic disorder that causes life-threatening complications within the child's immune system. Infants with SCID may present with an unusual frequency of common infections, chronic diarrhea, and failure to thrive. They may also present with a red, peeling rash resembling eczema that does not respond to topical steroid therapy.

Bone marrow stem cell transplantation is considered to be first-line therapy for the treatment of SCID. Immune reconstitution involves the palliative enhancement of immune function; IVIG is used to support the immune system prior to a stem cell transplant.

Live vaccines are contraindicated in infants with SCID due to the risk of severe reactions, including death. IV pain medication is not typically indicated for managing patients with SCID.

Correct answer: Apply a bag of ice to the face for 15 seconds

Vagal maneuvers are used initially for acute SVT to stop the arrhythmia. These maneuvers affect the vagus nerve, which sends signals to the AV node to control the heartbeat and ultimately can slow the heart rate. Coldwater treatment is a type of vagal maneuver that can be performed quickly and easily for an infant as a primary measure. Applying ice to the face stimulates the vagus nerve and may immediately reverse SVT.

If ice is not successful, pharmacologic therapy with adenosine for acute termination of the episode is then utilized. Chronic therapy with propranolol is started if the SVT is recurrent, prolonged, or hemodynamically important. DCCV or overdrive pacing if pacemaker wires are present is used for patients who are hemodynamically compromised.

Correct answer: Splenic 

Splenic injuries are the most common abdominal injury in pediatrics and are graded on a scale of I to V depending on the severity of splenic trauma, with a grade V laceration usually requiring a splenectomy. With a splenic injury, the chief complaints are usually upper abdominal pain in the left quadrant, referred left shoulder pain (during abdominal palpation) known as Kehr's sign, and sometimes chest pain. 

Renal injury presents with hematuria, abdominal pain, and flank hematomas. Hepatic injury presents with right referred shoulder pain. Pancreatic injury is not common in children due to the pancreas's location in the retroperitoneal space of the abdominal cavity. 

Correct answer: Stop the IV infusion on the pump and aspirate fluid from the catheter hub

Vesicants are highly irritating medications and solutions and should be either avoided or carefully monitored during infusion. Treatment for a vesicant medication should be determined before discontinuing the intravenous catheter, so the nurse's initial response should be to stop the infusion and aspirate fluid from the catheter hub.

If extravasation is determined to have occurred (i.e., leaking of IV fluids and medications into the tissue surrounding the vessel), immediate measures to reduce injury should be instituted. The device should be carefully removed, the extremity should be elevated, and the nurse should follow hospital protocol for further treatment guidelines.

Correct answer: Nausea and vomiting are present in DKA but absent in HHS

DKA is a life-threatening complication of diabetes mellitus (most often type 1 in children), and it occurs as a result of relative or absolute insulin deficiency. It is diagnosed when:

• blood glucose is >200 mg/dL
• venous pHis <7.3 or bicarbonate is <15 mmol/L
• kenonemia and/or ketonuria is/are present

Signs and symptoms of DKA include polyuria, polydipsia, polyphagia, weight loss, weakness and lethargy, nausea and vomiting, abdominal pain, dehydration, tachycardia, hypovolemia, poor perfusion, shock, glycosuria, ketonuria, rapid deep respirations (Kussmaul respirations), and stupor that can lead to coma.

Although HHS is rarely seen in children, it does happen. In HHS, a state of relative insulin deficiency is the result of insulin secretion that is adequate to prevent lipolysis but not substantial enough to prevent hyperglycemia. The degree of hyperglycemia, hyperosmolality, and dehydration is much greater in HHS than in DKA. Signs and symptoms can be initially vague, including mild signs of dehydration, headaches, and abdominal pain. Nausea and vomiting are not seen with HHS. Polyuria and polydipsia slowly progress, and neurologic impairment is significantly higher in children with HHS than in those with DKA due to hyperosmolality and its sequelae. The respiratory rate is normal with HHS, but a child may exhibit tachycardia, hypotension, low central venous pressure, shock, and stupor or coma.