Question 1

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?

Accepted Answer

The patient has the symptoms of heat exhaustion which occurs when the body loses water and electrolytes through heavy sweating that leads to hypovolemia.Fluid and electrolyte replacement are the priority for this patient.B.Antibiotics are not necessary; the elevated temperature is related to fluid and electrolyte loss.C.Chest x-ray is not required and is not the priority at this time.D.Tylenol for pain or elevated temperature is not the priority at this time.

Question 2

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

Accepted Answer

In mild hypothermia,the patient is usually alert,shivering,and may appear clumsy,apathetic,or irritable.Hypoglycemia can occur because glucose and glycogen stores are depleted by long-term shivering.C.Respiratory rate,heart rate,and cardiac output decrease.A.Pupils are dilated when temperature falls below 89.6°F.

Question 3

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.

Accepted Answer

Patients who are seriously injured and have the greatest chance of full recovery are treated first.This would be the patient with shortness of breath without any cardiac arrhythmia.The next patient would be the patient with a distended abdomen reporting abdominal pain.The child with a fractured humerus should be treated next.The patient with the foot laceration then be treated.The patient without any pulse or respirations could be seen last.

Question 4

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?

Accepted Answer

The profoundly hypothermic patient has a core temperature of less than 80°F (27°C)and usually appears dead,with no obtainable vital signs.A.Mild hypothermia is associated with a body temperature around 95.0F.B.A body temperature of 90.0F is associated with severe hypothermia.C.At 82.1°F the patient becomes lethargic and disoriented and begins to hallucinate.

Question 5

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?

Accepted Answer

Abdominal organs may be injured as a result of severe blunt or penetrating trauma.If hypotension is present,intra-abdominal hemorrhage may exist.A.A pH of 7.35 is within normal limits.C.A red macular rash on the patient's back would need further investigation however can be addressed at a later time.D.Weak distal pulses in the lower extremities would be consistent with the low blood pressure.

Question 6

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

Accepted Answer

The normal capillary refill time is 3 seconds.B.C.D.Capillary reflex times longer than 3 seconds could indicate shock.

Question 7

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

Accepted Answer

It is important to start with a complete assessment and information regarding recent use of alcohol or illicit drugs should be obtained because these substances can heighten psychiatric emergencies.A.Drug allergies can be obtained at a later time.C.Placing an order for food is not a priority at this time.D.Verbalization of feelings about the event can occur at a later time.

Question 8

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.)

Accepted Answer

A poisonous snakebite has two small puncture wounds with surrounding discoloration,swelling,and pain.A coral snake is poisonous; the bite produces burning pain at the site of the injury.Swelling and discoloration occur within 5 to 10 minutes after the bite.B.F.Cramping and cyanosis of the site of injury are not symptoms associated with a coral snake bite.

Question 9

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?

Accepted Answer

In a tension pneumothorax,air is trapped in the pleural space during exhalation,resulting in increased pressure on the unaffected lung.The heart,great vessels,and trachea shift toward the unaffected side of the chest.A.A patient with cardiac tamponade will have hypotension,tachycardia,and neck vein distention.B.C.Air or blood leaking into the intrapleural space collapses the lung,resulting in a pneumothorax or hemothorax and ineffective ventilation.

Question 10

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.)

Accepted Answer

The amputated part is rinsed with saline solution,wrapped in sterile gauze,and placed in a sealed plastic bag,which is then placed on ice.C.The amputated part is not covered with ice or in ice water.

Question 11

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.)

Accepted Answer

Care of the patient in shock includes providing oxygen as prescribed,measuring and recording vital signs,and providing IV fluids as prescribed.A.The patient should be kept supine.B.The patient should be kept at nothing by mouth status until the need for surgery has been ruled out.

Question 12

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

Accepted Answer

When treating anaphylaxis,epinephrine is given IM; antihistamines are given as second-line therapy to control the allergic rash and pruritus; and steroids are given in gradually tapered doses to prevent return of symptoms.B.D.Antibiotics and anticoagulants are not routinely used as treatment for anaphylaxis.

Question 13

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?

Accepted Answer

Heat exhaustion occurs when the body loses water and electrolytes through heavy sweating that leads to hypovolemia.The patient has the symptoms of heat exhaustion.A.Heatstroke is characterized by altered mental status,inability to sweat,hot,dry,flushed skin,and extremely high body temperature.B.Heat cramps are characterized by painful muscle spasms,usually in the legs or abdomen that occur after strenuous exercise.D.The patient's history of working in a non-air conditioned plant during hot weather is not consistent with an infectious process.

Question 14

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?

Accepted Answer

Tetanus vaccinations should begin at 2 months of age and be followed by a series of pediatric immunizations until age 15.Thereafter,booster vaccinations are recommended every 10 years in the absence of an open wound.If the patient received tetanus booster vaccinations as recommended,the most recent booster should have been at age 35.

Question 15

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.)

Accepted Answer

Headache,nausea/vomiting,amnesia,drowsiness,change in level of consciousness,and changes in speech are early signs and symptoms of increased ICP.D.F.Decreased pulse rate and dilated nonreactive pupils are late manifestations of ICP.

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