Deck 13: Nursing Care of Patients With Emergent Conditions and Disasterbioterrorism Response

Question 1

A patient involved in a car accident is brought to the emergency department. The nurse is asked to use the Glasgow Coma Scale. The patient opens eyes when spoken to and points to the location of pain but is confused in conversation. What would this patient's Glasgow Coma Scale score be?

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

Answer 1

12

Question 2

Which of these is a priority nursing diagnosis for a patient who is experiencing a manic episode?

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

Answer 2

Risk for Injury

Question 3

What is an appropriate nursing action to decrease the effects of venom for a patient who has been bitten on the left arm by a poisonous snake?

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

Answer 3

Keep the patient calm.

Question 4

A patient is brought to the emergency department after a motor vehicle accident. Which of these symptoms found during data collection should the nurse report promptly?

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

Question 5

Which of these statements by a patient who is experiencing a psychotic episode should the nurse recognize as evidence of a favorable response of reduced anxiety?

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

Question 6

Which medication is no longer recommended for use at home to induce vomiting for certain ingested poisons?

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

Question 7

The nurse assists with an educational program on bioterrorism. Symptoms of smallpox are discussed. The nurse would evaluate the participants as understanding the symptoms if they replied that the characteristic rash of smallpox typically first appears in which of the following places?

A)Legs and feet
B)Face and forearms
C)Abdomen and perineum
D)Neck and back

Question 8

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

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

Question 9

A patient is brought to the emergency room after being involved in a fire. The patient has thermal burns to the neck and shoulders and singed nasal hairs. Which of the following measures should the nurse do first?

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

Question 10

The primary survey of a patient hit by a car has been completed. The patient has an open airway and is breathing and conscious but is bleeding heavily from severe leg injuries. This patient is most at risk for what complication?

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

Question 11

The physician orders haloperidol (Haldol) 2 mg intramuscularly 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 12

The nurse in the emergency department is caring for a patient with a partial-thickness thermal burn?

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

Question 13

Which of these is a complication of vomiting when a patient has ingested a corrosive product?

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

Question 14

A patient who has fallen has superficial abrasions and an abdomen that is distended, firm, and tender when touched. This finding would most likely indicate to the nurse that the patient may be experiencing which of these complications?

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

Question 15

During a disaster with many patients, the triage nurse in the emergency department would give priority to which of the following patients?

A)A severely injured patient with less than 1% chance of survival.
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 full potential for recovery.

Question 16

What is the primary intervention for patients experiencing near-drowning?

A)Draining fluid from the lungs
B)Draining fluid from the stomach
C)Decompressing the stomach
D)Maintaining ventilation

Question 17

A patient suffers a head injury and has increased intracranial pressure. In which of the following positions should the nurse maintain the patient's head to assist in reducing intracranial pressure?

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

Question 18

Which of these methods should the nurse use to cleanse a poisonous snakebite wound?

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

Question 19

After establishment of airway patency in a trauma patient, which of these steps is a priority?

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

Question 20

Which of these medications is used when rapid tranquilization is required for a psychiatric emergency?

A)Diphenhydramine (Benadryl)
B)Haloperidol (Haldol)
C)Diazepam (Valium)
D)Hydroxyzine (Vistaril)

Question 21

A patient with severe hypothermia is comatose with fixed dilated pupils, flaccid muscles, and ventricular fibrillation. The core body temperature of this patient is most likely below ____________________°F.Other

Question 22

A patient is admitted for mild hypothermia. Which of the following signs or symptoms should the nurse expect to find? (Select all that apply.?

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

Question 23

Normal capillary refill time is ________________second(s).

Question 24

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 25

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

A)Instruct the student how to place an order with dietary services.
B)Determine if alcohol or illicit drugs have been used recently.
C)Encourage the patient to verbalize his or her feelings about the event.
D)Obtain a list of drug allergies from the student.Multiple Response
Identify one or more choices that best complete the statement or answer the question.

Question 26

Which of the following would the nurse recognize as signs or symptoms of the early stage of increased intracranial pressure (ICP)? (Select all that apply.?

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

Question 27

The nurse is caring for a patient who reports being bitten by a coral snake less than an hour ago. Which of the following symptoms would the nurse expect to see? (Select all that apply.?

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

Question 28

The nurse is caring for a patient who has sustained abdominal injury in a motor vehicle accident. Which of the following symptoms would be most concerning?

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

Question 29

In the middle of the summer, a homeless individual is brought to the hospital. The patient reports feeling weak and faint and having a headache. The patient seems irritable and his skin is cool and clammy. Vital signs are: temperature 99.9°F, pulse 100 bpm, respirations 18/minute, blood pressure 108/60 mm Hg. What would be the appropriate action for the nurse to take?

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

Question 30

After several days of hot and humid weather conditions, a patient is brought to the hospital with cold, clammy skin. The patient reports feeling weak and faint and having a headache. The patient seems irritable. Vital signs indicate a slightly elevated temperature and rapid pulse but no other signs of illness. What diagnosis should the nurse anticipate?

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