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CEN Practice Exam (Certified Emergency Nurse)

Category - Shock

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Your patient has come into the emergency department with a self-inflicted wrist laceration that has severe bleeding. You have begun to apply pressure to the wound. What would your immediate priority be?
  1. See to the patient’s need for psychiatric evaluation.
  2. Lower the patient’s body temperature to decrease circulation.
  3. Place the extremity below the level of the heart.
  4. Monitor the patient for signs of shock.
Explanation
Answer: D - The nurse would need to monitor this patient for hypovalemic shock. Symptoms of shock would include tachycardia, cool, clammy skin and a change in level of consciousness. Hypovolemia leads to vasoconstriction and shunting of blood to central circulation. The patient will need to have a psychiatric evaluation, but it is not priority.
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