test 6

72. An adolescent sustains a T3 spinal cord injury. After insertion of an intravenous line, a nasogastric tube, and an indwelling urinary (Foley) catheter, the adolescent is admitted to the intensive care unit. What should the nurse do next when assessment reveals that the adolescent's feet and legs are cool to the touch? 1. Cover the adolescent's legs with blankets. 2. Report this finding to the primary health care provider immediately. 3. Reposition the adolescent's legs. 4. Lay the adolescent flat to aid circulation.

1

75. A school-age boy with a spinal cord injury is moved to the rehabilitation unit. The nurse notes that the child tends to refuse to cooperate in care and to be hostile. The nurse interprets this behavior as indicative of which of the following? 1. A stage of grief reaction. 2. A phase of rebellion. 3. A reaction to sensory overload. 4. A response to too much attention.

1

27. A number of clients have come to the emergency department after a possible terrorist act of arsenic overexposure. The nurse should assess these clients for which signs or symptoms immedi dely following the poisoning? Select all that apply. 1. Violent vomiting. 2. Severe diarrhea. 3. Abdominal pain. 4. Sensory neuropathy. 5. Persistent cough.

123

29. The nurse is triaging victims of an earth- quake who were removed from a building when the earthquake occurred. Which of the following victims should be classified as red? Select all that apply. 1. A 10-year-old male with crushing chest wound, tachypnea with labored breathing, unconscious, impaled object in forehead. 2. A 49-year-old male with crushing chest pain radiating to the jaw, is diaphoretic, nause- ated, and has an open fracture of the left wrist. 3. A 75-year-old female with obvious fracture of the femur, absent pedal pulses on the affected side; heart rate 110, respirations 34, skin diaphoretic; awake/alert, states pain is 10 on a scale of 1 to 10. 4. A 32-year-old female who is unconscious, 3-inch (7.6-cm) laceration to her forehead, ecchymosis behind the ears, respiratory rate 10/shallow; radial pulse is weak/thread/ rapid; no breath sounds on the right side.

23

20. The client has expired secondary to smallpox. Which information about funeral arrangements is most important for the nurse to provide to the client's family? 1. The client should be cremated. 2. Suggest an open casket funeral. 3. Bury the client within 24 hours. 4. Notify the public health department.

1

14. The health-care facility has been notified an alleged inhalation anthrax exposure has occurred at the local post office. Which category of personal protective equipment (PPE) should the response team wear? 1. Level A 2. Level B. 3. Level C. 4. Level D.

1

15. The nurse is reviewing laboratory values of a client receiving clozapine. Which of the follow- ing laboratory values should the nurse report to the health care provider? 1. WBC of 3,500/ML (3.5 × 10°/L) 2. Hemoglobin of 8.2 g/dL (82 g/L) 3. Sodium level of 136 4. Hyaline casts in the urinalysis

1

16. The nurse is planning care for a client who has sustained a spinal cord injury. The nurse should assess the client for: 1. Anesthesia below the level of the injury. 2. Tingling in the fingers. 3. Pain below the site of the injury. 4. Loss of vibratory sense.

1

25. Several clients who work in the same building are brought to the emergency department. They all have fever, headache, a rash over the entire body, and abdominal pain with vomiting and diarrhea. Upon initial assessment, the nurse finds that each client has low blood pressure and has developed petechiae in the area where the blood pressure cuff was inflated. Which isolation precautions should the nurse initiate? 1. Contact isolation with double-gloving and shoe covers. 2. Respiratory isolation with positive pressure rooms. 3. Enteric precautions. 4. Reverse isolation.

1

The nurse is teaching a class on bioterror Which statement is the scientific rationale for designating a specific area for decontamination? 1. showers and privacy can be provided to the client in this area. 2. This area isolates the clients who have been exposed to the agent. 3. It provides a centralized area for stocking the needed supplies. 4. It prevents secondary contamination to the health-care providers.

4

22. The nurse is caring for a client in the prodromal phase of radiation exposure. Which signs/ symptoms should the nurse assess in the client? 1. Anemia, leukopenia, and thrombocytopenia. 2. Sudden fever, chills, and enlarged lymph nodes. 3. Nausea, vomiting, and diarrhea. 4. Flaccid paralysis, diplopia, and dysphagia.

3

74. Which of the following findings should lead the nurse to decide that spinal shock was resolving in the adolescent with a spinal cord injury? 1. Atonic urinary bladder. 2. Flaccid paralysis. 3. Hyperactive reflexes. 4. Widened pulse pressure.

3

87. A client was brought to the emergency department following a motor vehicle accident, and has phrenic nerve involvement. The nurse should asses the client for: 1. Alteration in level of consciousness. 2. Altered cardiac functioning. 3. Ineffective breathing pattern. 4. Alteration in urinary elimination.

3

19. Which signs/symptoms should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin? 1. A scabby, clear fluid-filled vesicle. 2. Edema, pruritus, and a 2-mm ulcerated vesicle. 3. Irregular brownish-pink spots around the hairline. 4. Tiny purple spots flush with the surface of the skin.

2

A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers? 1. Hold their breath as much as possible. 2. Stand up to avoid heavy exposure. 3. Lie down to stay under the exposure. 4. Attempt to breathe through their clothing.

2

During assessment of an adolescent who has sustained a recent thoracic spinal injury, the nurse auscultates the adolescent's abdomen. The nurse explains to the parents that this is necessary because clients with spinal cord injury often develop which of the following? 1. Abdominal cramping 2. Hyperactive bowel sounds. 3. Paralytic ileus. 4. Profuse diarrhea.

3

The nurse is evaluating the pin insertion site of a client's skeletal traction. Which of the following indicate a complication? 1. Presence of crusts around the pin insertion site. 2. Serous drainage on the dressing. 3. Slight movement of pin at insertion site. 4. No pain felt by the client at insertion site.

3

A nurse who witnesses an accident involving an adolescent riding a motorcycle, hitting a tree, and being thrown 30 feet (914.4 cm) into a field stops to help. The adolescent reports that he is now unable to move his legs. While waiting for the emer- gency medical service to arrive, what should the nurse do? 1. Flex the adolescent's knees to relieve stress on his back. 2. Leave the adolescent as he is, staying close by. 3. Remove the adolescent's helmet as soon as possible. 4. Assess the adolescent for abdominal trauma.

2

The nurse in the emergeney department has admitted five (5) clients in the last two (2) hours with complaints of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat? 1,"Do you work or live near any large power lines?" 2."Where were you immediately before you got sick?" 3."Can you write down everything you ate today?" 4.«What other health problems do you have?"

2

Several clients come to the emergency depart- ment with suspected contamination by the Ebola virus. What should the nurse do? Select all that apply. 1. Call in extra staff to assist with the possibility of more clients with the same condition. 2. Isolate all the suspected clients in the emergency department in one area. 3. Call housekeeping for diluted household bleach. 4. Restrict visitors from the emergency department. 5. Quarantine all contacts.

234

107 The community health nurse is triaging victims at the scene of a building collapse. Which intervention should the nurse implement first? 1. Discuss the disaster situation with the media. 2. Write the client's name clearly in the disaster log. 3. Place disaster tags securely on the victims. 4. Identify an area for family members to wait.

3

141. To reduce the risk of pressure ulcer formation, which of the following activities should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury? 1. Bathe daily. 2. Eat a high-carbohydrate diet. 3. Shift your weight every 15 minutes. 4. Move from the bed to the wheelchair every 2 hours.

3

15. The nurse is teaching a class on bioterrorism and is discussing personal protective equipment (PPE). Which statement is the most important fact for the nurse to share with the participants? 1. Health-care facilities should keep masks at entry doors. 2. The respondent should be trained in the proper use of PPE. 3. No single combination of PPE protecis against all hazards. 4. The EPA has divided PPE into four levels of protection.

3

17. A client who is paraplegic cannot feel the lower extremities and has been positioned on the side. The nurse should inspect which of the follow- ing areas that is a potential pressure point when the client is in this position? 1. Sacrum. 2. Occiput. 3. Ankles. 4. Heels.

3

17. The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department? 1. Triage the clients and send them to the appropriate areas. 2. Thoroughly wash the clients with soap and water and then rinse. 3. Remove the clients' clothing and have them shower. 4. Assume the clients have been decontaminated at the plant.

3

76. Two months after an adolescent's thoracic spinal cord injury, he has a pounding headache. The nurse notes that the client's arms and face are flushed and he is diaphoretic. What should the nurse do next? 1. Check the patency of the urinary catheter. 2. Lower the adolescent's head below his knees. 3. Place the adolescent flat on his back. 4. Prepare to administer epinephrine subcutaneously.

1

A client with a T2-to-T3 spinal cord injury suddenly has a throbbing headache and blurred vision. The client is flushed and sweating on the upper trunk and face, and the hairs on the arms are raised. What should the nurse do first? 1. Raise the head of the bed. 2. Assess for hypotension. 3. Check the client for a distended bladder. 4. Logroll the client to see if the client is lying on a foreign object.

1

23. Which cultural issues should the nurse consider when caring for clients during a bioterrorism attack? Select all that apply. 1. Language difficulties. 2. Religious practices. 3. Prayer times for the people. 4. Rituals for handling the dead. 5. Keeping the family in the designated area.

1234

105. The community health nurse is triaging victims at a bus accident. Which client would the nurse categorize as red, priority 1? 1. The client with head trauma whose pupils are fixed and dilated. 2. The client with compound fractures of the tibia and fibula. 3. The client with a sprained right wrist with a 1-inch laceration. 4. The client with a piece of metal embedded in the right eye.

2

24. A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospi- tal, what type of precautions should the nurse institute? 1. Enteric precautions. 2. Hand-washing precautions. 3. Reverse isolation. 4. Standard precautions.

4

24. The off-duty nurse hears on the television of a bioterrorism act in the community. Which action should the nurse take first? 1. Immediately report to the hospital emergency department. 2. Call the American Red Cross to find out where to go. 3. Pack a bag and prepare to stay at the hospital. 4. Follow the nurse's hospital policy for responding.

4

28. Eight farm workers are admitted to the emer- gency department after they were splashed with couple of chemicals" at work 30 minutes ago. They have watery/itchy eyes, slight cough, diaphoresis, constricted pupils, and are conscious and oriented. Their clothes are wet. What action should the nurse do first? 1. Apply oxygen at 3 L per nasal cannula 2. Remove their clothing. 3. Begin decontamination shower 4. Isolate the clients.

4

The nurse is assessing a child's skeletal trac- tion and notices that the weights are on the floor. Which of the following should the nurse do next? 1. Raise the weights so that the child can move up in bed 2. Notify the primary care provider immediately. 3. Put the foot of the bed on blocks. 4. Move the child up in bed

4

A suspected outbreak of anthrax has been mismitted by skin exposure. A client is admit. lad to the emergency, department with lesions on he hands. The physician prescribes antibiotics and sends the client home. What should the nurse hastruct the client to do? Select all that apply. 1. Take the prescribed antibiotics for 60 days. 2. Avoid contact with other members of the family during the treatment period. 3. Wear a mask for 60 days. 4. Expect the skin lesions to clear up within 1 to 2 weeks. 5. Wash hands frequently.

14

1792. Which injured client of a mass casualty disaster should a triage nurse in an emergency department establish as the priority client? 1. An unresponsive client with a penetrating head injury. 2, A partially responsive client with a sucking chest wound. 3. A client with a maxilla fracture and facial wounds without airway compromise. 4. A client with third-degree burns over 65% of the body surface area.

2

The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation? 1. Contaminated water is the only source of transmission of biological agents. 2. Vaccines are available and being prepared to counteract biological agents. 3. Biological weapons are less of a threat than chemical agents. 4. Biological weapons are easily obtained and result in significant mortality.

4

30. The nurse is assessing the client (see photo below) who has recently returned from a 2-month mission in Africa. What type of respiratory protec- tion is appropriate for the staff? 1. N95 particulate respirator. 2. Double-layered surgical mask. 3. Surgical mask with eye shield. 4. No respiratory protection is needed.

1