Deck 13: Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response

Question 1

The nurse is evaluating care provided to a patient recovering from a psychotic episode.Which patient statement should the nurse recognize as an indication of reduced anxiety?

A) "I feel calm."
B) "I like the nurses."
C) "The restraints can be removed."
D) "I do not need any tranquilizers."

Answer 1

"I feel calm."

Question 2

The nurse in the emergency department is caring for a patient with a partial-thickness thermal burn.Which treatment should the nurse expect to be prescribed for this patient?

A) Application of wet dressings
B) Use of clean dressing technique
C) Application of moisturizing lotion
D) Application of silver sulfadiazine cream

Answer 2

Application of silver sulfadiazine cream

Question 3

The nurse in the emergency department is triaging victims of a building collapse.Which victim should the nurse determine is a priority for care?

A) A severely injured patient with full potential for recovery
B) A severely injured patient with slight potential for survival
C) A severely injured patient with moderate potential for survival
D) A severely injured patient with less than 1% chance of survival

Answer 3

A severely injured patient with full potential for recovery

Question 4

The nurse is planning care for a patient who experienced a near-drowning.What should the nurse identify as the goal of care for this patient?

A) Maintain ventilation
B) Decompress the stomach
C) Drain fluid from the lungs
D) Drain fluid from the stomach

Question 5

The nurse is preparing teaching for the home treatment of ingested poisons.Which medication is no longer recommended for use at home to induce vomiting for certain ingested poisons?

A) Syrup of ipecac
B) Cimetidine (Tagamet)
C) Thiethylperazine (Torecan)
D) Prochlorperazine (Compazine)

Question 6

The nurse assists with the provision of an educational program on the symptoms of smallpox.Which response indicates that the participants understand the location that the rash first appears?

A) Legs and feet
B) Neck and back
C) Tongue and face
D) Abdomen and perineum

Question 7

A patient who has fallen has superficial abrasions and an abdomen that is distended,firm,and tender when touched.Which complication should the nurse consider that this patient is experiencing?

A) Anaphylaxis
B) Emotional stress
C) Cardiac arrhythmia
D) Internal abdominal bleeding

Question 8

A patient who sustained multiple injuries in a motor vehicle crash is brought to the emergency department.After the primary survey,what should be the nurse's next action?

A) Explain to the patient what happened.
B) Prepare patient for surgery immediately.
C) Complete out a rapid head-to-toe assessment.
D) Obtain a medical history from a family member.

Question 9

The results of a primary survey reveal that a victim of a motor vehicle crash has an open airway,is breathing,and is conscious but bleeding heavily from severe leg injuries.For which complication should the nurse plan care for this client?

A) Anaphylaxis
B) Hemothorax
C) Cardiogenic shock
D) Hypovolemic shock

Question 10

The physician orders haloperidol (Haldol)2 mg intramuscularly (IM)for a patient who is experiencing a psychiatric crisis.Haldol 5 mg/mL is available.How many milliliters should the nurse give?

A) 0.3 mL
B) 0.4 mL
C) 1 mL
D) 1.5 mL

Question 11

When using the Glasgow Coma Scale for a patient involved in a motor vehicle crash,the patient opens the eyes when spoken to and points to the location of pain but is confused in conversation.What score should the nurse assign to this patient?

A) 8
B) 10
C) 12
D) 14

Question 12

A patient with a head injury is diagnosed with increased intracranial pressure.In which position should the nurse maintain the patient's head to assist in reducing intracranial pressure?

A) Flexed
B) Midline
C) Turned to left side
D) Turned to right side

Question 13

The nurse is preparing to care for a client with a poisonous snake wound.Which method should the nurse use to cleanse the site?

A) Wash with soap and water.
B) Scrub with hydrogen peroxide.
C) Rinse with normal saline, and apply Betadine.
D) Soak in povidone-iodine (Betadine) for 10 minutes.

Question 14

The nurse is caring for a patient who was bitten by a snake.Which action should the nurse take to decrease the effects of the venom?

A) Keep the patient calm.
B) Elevate the patient's limb.
C) Encourage the patient to ambulate.
D) Perform passive range of motion on the affected limb.

Question 15

A patient who has ingested a corrosive product is vomiting.For which potential complication should the nurse prepare to provide care to this client?

A) Coma
B) Esophageal burns
C) Chemical pneumonia
D) Aspiration pneumonia

Question 16

The nurse ensures that a trauma patient has an effective airway.On what should the nurse focus after the airway has been established for this patient?

A) Exposure
B) Disability
C) Breathing
D) Circulation

Question 17

A patient is brought to the emergency department after a motor vehicle crash.Which symptom assessed during data collection should the nurse report promptly?

A) Oliguria
B) Wheezing
C) Ecchymosis
D) Tachycardia

Question 18

A patient seeking treatment after being in a house fire has thermal burns to the neck and shoulders and singed nasal hairs.Which action should the nurse take first?

A) Monitor respirations.
B) Monitor urine output.
C) Obtain blood pressure.
D) Place the patient in a private room.

Question 19

The nurse is caring for a patient experiencing acute psychosis.What should the nurse realize as being the purpose of medication for this patient?

A) Encourage sleep
B) Reduce psychosis
C) Improve cognition
D) Enhance oxygenation

Question 20

The nurse is planning care for a patient with a mental health disorder.Which nursing diagnosis should the nurse select if the patient is demonstrating manic behavior?

A) Grieving
B) Confusion
C) Risk for Injury
D) Defensive Coping

Question 21

A homeless person is brought to the hospital for weakness,feeling faint,and having a headache.The patient's skin is cool and clammy and vital signs are temperature 99.9°F,pulse 100 bpm,respirations 18/minute,blood pressure 108/60 mm Hg.What action should the nurse take?

A) Provide oral fluids.
B) Provide Ciprofloxin 400 mg intravenously (IV).
C) Prepare the patient for a chest x-ray.
D) Provide acetaminophen (Tylenol) 500 mg orally.

Question 22

A patient is admitted for mild hypothermia.Which manifestations should the nurse expect when assessing this patient? (Select all that apply.)

A) Pinpoint pupils
B) Depleted glucose stores
C) Increased respiratory rate
D) Decreased respiratory rate
E) Decreased muscular activity
F) Decreased heart rate and cardiac output

Question 23

The nurse is helping triage in the emergency department as victims of an explosion are being brought in.Rank (1-5)the following patients according to their need for priority treatment according to disaster response protocols and best chance of survival.

A) _____ A 15-year-old with a laceration to the foot that is bleeding slightly
B) _____ A 36-year-old who has no pulse or respirations and has an open head injury
C) _____ A 70-year-old with shortness of breath but no detectable cardiac arrhythmias
D) _____ A 5-year-old with a suspected fracture of the humerus
E) _____ A 58-year-old woman with a distended abdomen who reports severe abdominal pain

Question 24

A patient with severe hypothermia is comatose with fixed dilated pupils,flaccid muscles,and ventricular fibrillation.Which body temperature should the nurse expect to assess in this patient?

A) 95.0
B) 90.0
C) 82.1
D) 80.6

Question 25

The nurse is caring for a patient who has sustained an abdominal injury in a motor vehicle crash.Which symptom should be the most concerning to the nurse?

A) pH 7.35
B) Blood pressure 104/52 mm Hg
C) A red macular rash on the patient's back
D) Weak distal pulses in the lower extremities

Question 26

The nurse determines that a patient has a normal capillary refill time.What was this patient's refill time?

A) 3 seconds
B) 4 seconds
C) 5 seconds
D) 6 seconds

Question 27

The nurse is providing care to a college student having a psychiatric emergency and related suicide attempt.Which action should the nurse take first?

A) Obtain a list of drug allergies from the student.
B) Determine if alcohol or illicit drugs have been used recently.
C) Instruct the student how to place an order with dietary services.
D) Encourage the patient to verbalize his or her feelings about the event.

Question 28

The nurse is caring for a patient who reports being bitten by a coral snake less than an hour ago.Which symptoms should the nurse expect to assess in this patient? (Select all that apply.)

A) Two small puncture wounds
B) Cramping of large muscle groups
C) Localized swelling at the site of the bite
D) Reports of burning pain at the site of injury
E) Discoloration surrounding the site of the bite
F) A pale mottled cyanotic center at the site of injury

Question 29

While assessing a victim of a motor vehicle crash,the nurse notes that the patient's trachea is shifted towards the left.What does this finding indicate to the nurse?

A) Cardiac tamponade
B) Right lung hemothorax
C) Left lung pneumothorax
D) Right lung tension pneumothorax

Question 30

The nurse is receiving a victim of a traumatic amputation in the emergency department.What should the nurse do with the amputated limb? (Select all that apply.)

A) Place on ice
B) Rinse with saline
C) Place in ice water
D) Wrap in sterile gauze
E) Place in a sealed plastic bag

Question 31

A patient brought into the emergency department is diagnosed with shock.Which interventions should the nurse prepare to provide to this patient? (Select all that apply.)

A) Raise the head of the bed.
B) Encourage sips of warm fluid.
C) Provide oxygen as prescribed.
D) Measure and record vital signs.
E) Provide IV fluids as prescribed.

Question 32

A patient is experiencing an anaphylactic reaction to peanuts.Which medication should the nurse prepare to administer to this patient? (Select all that apply.)

A) Steroids
B) Antibiotics
C) Epinephrine
D) Anticoagulants
E) Antihistamines

Question 33

A patient who works in a non-air conditioned manufacturing plant is experiencing weakness and a headache.The patient's skin is cool and clammy,temperature is slightly elevated,and pulse rate is rapid.For which health problem should the nurse plan care for this patient?

A) Heatstroke
B) Heat cramps
C) Heat exhaustion
D) Initial signs of infection

Question 34

The nurse is reviewing a 40-year-old patient's immunization schedule.At which age should the patient have received the most recent tetanus booster vaccination?

A) 2 months
B) 6 years
C) 20 years
D) 35 years

Question 35

The nurse is caring for a patient with a traumatic brain injury.What should the nurse recognize as manifestations of early increased intracranial pressure (ICP)? (Select all that apply.)

A) Amnesia
B) Headache
C) Drowsiness
D) Decreased pulse rate
E) Nausea and vomiting
F) Dilated nonreactive pupils