Chapter 68: Disaster Nursing

13. A nurse takes a shift report and will be caring for a client who has been exposed to anthrax by inhalation. What precautions does the nurse know must be put in place when providing care for this client? A. Standard precautions B. Airborne precautions C. Droplet precautions D. Contact precautions

A. Standard precautions Rationale: The client is not contagious, and anthrax cannot be spread from person to person, so standard precautions are initiated. Airborne, contact, and droplet precautions are not necessary.

9. The announcement is made that the facility may return to normal functioning after a local disaster. In the emergency operations plan, what is this referred to as? A. Demobilization response B. Post-incident response C. Crisis diffusion D. Reversion

A. Demobilization response Rationale: The demobilization response occurs when it is deemed that the facility may return to normal daily functioning. This is not known as the post-incident response, crisis diffusion, or reversion.

26. A nurse is participating in the planning of a hospital's emergency operations plan. The nurse is aware of the potential for ethical dilemmas during a disaster or other emergency. Ethical dilemmas in these contexts are best addressed by which of the following actions? A. Having an ethical framework in place prior to an emergency B. Allowing staff to provide care anonymously during an emergency C. Assuring staff that they are not legally accountable for care provided during an emergency D. Teaching staff that principles of ethics do not apply in an emergency situation

A. Having an ethical framework in place prior to an emergency Rationale: Nurses can plan for the ethical dilemmas they may face during disasters by establishing a framework for evaluating ethical questions before they arise and by identifying and exploring possible responses to difficult clinical situations. Ethical principles do not become wholly irrelevant in emergencies. Care cannot be given anonymously and accountability for practice always exists, even in an emergency.

18. There has been a radiation-based terrorist attack and a client is experiencing vomiting, diarrhea, and shock after the attack. How will the client's likelihood of survival be characterized? A. Probable B. Possible C. Improbable D. Extended

C. Improbable Rationale: Clients who experience vomiting, diarrhea, and shock after radiation exposure are categorized as improbable survival, because they are demonstrating symptoms of exposure levels of more than 800 rads of total body-penetrating irradiation.

38. A client has been exposed to a nerve agent in a biochemical terrorist attack. This type of agent bonds with acetylcholinesterase, so that acetylcholine is not inactivated. What is the pathologic effect of this type of agent? A. Hyperstimulation of the nerve endings B. Temporary deactivation of the nerve endings C. Binding of the nerve endings D. Destruction of the nerve endings

A. Hyperstimulation of the nerve endings Rationale: Nerve agents can be inhaled or absorbed percutaneously or subcutaneously. These agents bond with acetylcholinesterase, so that acetylcholine is not inactivated; the adverse result is continuous stimulation (hyperstimulation) of the nerve endings. Nerve endings are not deactivated, bound, or destroyed.

34. The ED staff has been notified of the imminent arrival of a client who has been exposed to chlorine. The nurse should anticipate the need to address what nursing diagnosis? A. Impaired gas exchange B. Decreased cardiac output C. Chronic pain D. Excess fluid volume

A. Impaired gas exchange Rationale: Pulmonary agents, such as phosgene and chlorine, destroy the pulmonary membrane that separates the alveolus from the capillary bed, disrupting alveolar- capillary oxygen transport mechanisms. Capillary leakage results in fluid-filled alveoli and gas exchange ceases to occur. Pain is likely, but is acute rather than chronic. Fluid volume excess is unlikely to be a priority diagnosis and cardiac output will be secondarily affected by the pulmonary effects.

15. A client is being treated in the ED following a terrorist attack. The client is experiencing visual disturbances, nausea, vomiting, and behavioral changes. The nurse suspects this client has been exposed to what chemical agent? A. Nerve agent B. Pulmonary agent C. Vesicant D. Blood agent

A. Nerve agent Rationale: Nerve agent exposure results in visual disturbances, nausea and vomiting, forgetfulness, irritability, and impaired judgment. This presentation is not suggestive of vesicants, pulmonary agents, or blood agents.

7. A major earthquake has occurred within the vicinity of the local hospital. The nursing supervisor working the night shift at the hospital receives information that the hospital disaster plan will be activated. The supervisor will need to work with what organization responsible for coordinating interagency relief assistance? A. Office of Emergency Management B. Incident Command System C. Centers for Disease Control and Prevention (CDC) D. American Red Cross

A. Office of Emergency Management Rationale: The Office of Emergency Management coordinates the disaster relief efforts at state and local levels. The Incident Command System is a management tool to organize personnel, facilities, equipment, and communication in an emergency situation. The CDC is the agency for disease prevention and control and it supports state and local health departments. The American Red Cross provides additional support.

23. A hospital's emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do? A. Perform life-saving measures. B. Classify clients according to acuity. C. Provide health promotion education. D. Modify the emergency operations plan

A. Perform life-saving measures. Rationale: In an emergency, clients are immediately tagged and transported or given life-saving interventions. One person performs the initial triage while other emergency medical services (EMS) personnel perform life-saving measures and transport clients. Health promotion is not a priority during the acute stage of the crisis. Classifying clients is the task of the triage nurse. EMS personnel prioritize life-saving measures; they do not modify the operations plan.

35. The nursing supervisor at the local hospital reports that your hospital will be receiving multiple trauma victims from a blast that occurred at a local manufacturing plant. The paramedics call in a victim of the blast with injuries including a head injury and hemorrhage. What phase of blast injury should the nurse expect to treat in this client? A. Primary phase B. Secondary phase C. Tertiary phase D. Quaternary phase

A. Primary phase Rationale: Pulmonary barotraumas, including pulmonary contusions; head injuries, including concussion, other severe brain injuries; tympanic membrane rupture, middle ear injury; abdominal hollow organ perforation; and hemorrhage are all injuries that can occur in the primary phase of a blast. These particular injuries are not characteristic of the subsequent phases.

28. A client survived a workplace accident that claimed the lives of many of the client's colleagues several months ago. The client has recently sought care for the treatment of depression. How should the nurse best understand the client's current mental health problem? A. The client is experiencing a common response following a disaster. B. The client fails to appreciate the fact that the client survived the disaster. C. The client most likely feels guilty about actions the client took during the disaster. D. The client's depression most likely predated the disaster

A. The client is experiencing a common response following a disaster. Rationale: Depression is a common response to disaster. It does not suggest that the client feels guilty about the client's actions or that the client does not appreciate surviving. It is possible, but less likely, that the client was depressed prior to the disaster.

12. A client with smoke inhalation arrives at the emergency department (ED) after involvement in a house fire and is lethargic with tachypnea and tachycardia. The nurse anticipates what specific intervention(s) for this client? Select all that apply. A. Intubation and ventilator support. B. Treatment in a hyperbaric chamber. C. Hydroxocobalamin medication administration D. Receive nitrate pearls through the ventilator. E. Pralidoxime medication administration

A. Intubation and ventilator support. B. Treatment in a hyperbaric chamber. C. Hydroxocobalamin medication administration Rationale: Rapid administration of amyl nitrate, sodium nitrite, and sodium thiosulfate is essential to the successful management of cyanide exposure. First, the client is intubated and placed on a ventilator. In facilities where a hyperbaric chamber is available, it may be used to provide oxygenation before other therapies are initiated. An alternative suggested treatment for cyanide poisoning is hydroxocobalamin (vitamin B12a). Hydroxocobalamin binds cyanide to form cyanocobalamin (vitamin B12).The production of methemoglobin, which is produced by receiving nitrate pearls, is contraindicated in clients with smoke inhalation because they already have decreased oxygen-carrying capacity secondary to the carboxyhemoglobin produced by smoke inhalation. Pralidoxime is a medication for nerve agents that provides an antidote which allows cholinesterase to become active against acetylcholine.

25. A nurse has been called for duty during a response to a natural disaster. In this context of care, the nurse should expect to do which of the following? A. Practice outside of the nurse's normal area of clinical expertise. B. Perform interventions that are not based on assessment data. C. Prioritize psychosocial needs over physiologic needs. D. Prioritize the interests of older adults over younger clients.

A. Practice outside of the nurse's normal area of clinical expertise Rationale: During a disaster, nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by health care providers or advanced practice nurses.

1. The emergency department (ED) received news of a train derailment locally and the number of clients injured is reported between 50 and 100. The hospital has determined that it can accommodate 50 clients and still remain self-sufficient. What criteria is the hospital using to project the number of clients it can support? A. The understanding that the institution can rely on outside services after 3 days B. Based on the emergency operations plan that incorporates assistance from the Red Cross C. Decided by the institution's ability to sustain core services for at least 96 hours D. Based on the hospital's incident command system that updates the hospital on the severity of injuries

ANS: C Decided by the institution's ability to sustain core services for at least 96 hour Rationale: The emergency preparedness planning committee must have a realistic understanding of its resources. The goal of each health care institution is to remain self-sufficient to provide and sustain core services without the support of external assistance for at least 96 hours from the inception of the incident; ideally, this self-sufficiency should last for 7 days. The institution cannot expect outside services to be available to help until after 96 hours, which is 4 days. The emergency operations plan details how the facility will respond to a mass casualty incident and may include criteria for utilizing external resources, but external assistance from the Red Cross would not be a factor in determining how many clients the facility can realistically care for immediately. External resources such as the Red Cross cannot be accessed and utilized immediately. The field incident command, not the hospital's incident command center, will provide an estimate of number of clients that will be arriving, though severity of injuries and number of clients self-reporting may not be known.

27. A nurse is undergoing debriefing with the critical incident stress management (CISM) team after participating in the response to a disaster. During this process, the nurse will do which of the following? A. Evaluate the care that he or she provided during the disaster. B. Discuss the nurse's own emotional responses to the disaster. C. Explore the ethics of the care provided during the disaster. D. Provide suggestions for improving the emergency operations plan.

B. Discuss the nurse's own emotional responses to the disaster. Rationale: In debriefing, participants are asked about their emotional reactions to the incident, what symptoms they may be experiencing (e.g., flashbacks, difficulty sleeping, intrusive thoughts), and other psychological ramifications. The EOP and the care the nurse provided are not evaluated.

24. A nurse is triaging clients after a chemical leak at a nearby fertilizer factory. What is the guiding principle of this activity? A. Assigning a high priority to the most critical injuries B. Doing the greatest good for the greatest number of people C. Allocating resources to the youngest and most critical D. Allocating resources on a first-come, first-served basis

B. Doing the greatest good for the greatest number of people Rationale: In non-disaster situations, health care workers assign a high priority and allocate the most resources to those who are the most critically ill. However, in a disaster, when health care providers are faced with a large number of casualties, the fundamental principle guiding resource allocation is to do the greatest good for the greatest number of people. A first-come, first-served approach is unethical.

21. An industrial site has experienced a radiation leak and workers who have been potentially affected are en route to the hospital. To minimize the risks of contaminating the hospital, managers should perform what action? A. Place all potential victims on reverse isolation. B. Establish a triage outside the hospital. C. Have hospital staff put on personal protective equipment. D. Place hospital staff on abbreviated shifts of no more than 4 hours

B. Establish a triage outside the hospital. Rationale: Triage outside the hospital is the most effective means of preventing contamination of the facility itself. None of the other listed actions has the potential to prevent the contamination of the hospital itself.

4. A nurse is caring for clients exposed to a terrorist attack involving chemicals. The nurse has been advised that personal protective equipment must be worn in order to give the highest level of respiratory protection with a lesser level of skin and eye protection. What level protection is this considered? A. Level A B. Level B C. Level C D. Level D

B. Level B Rationale: Level B personal protective equipment provides the highest level of respiratory protection, with a lesser level of skin and eye protection. Level A provides the highest level of respiratory, mucous membrane, skin, and eye protection. Level C incorporates the use of an air-purified respirator, a chemical resistant coverall with splash hood, chemical resistant gloves, and boots. Level D is the same as a work uniform.

39. A group of military nurses are reviewing the care of victims of biochemical terrorist attacks. The nurses should identify what agents as having the shortest latency? A. Viral agents B. Nerve agents C. Pulmonary agents D. Blood agents

B. Nerve agents Rationale: Latency is the time from absorption to the appearance of signs and symptoms. Sulfur mustards and pulmonary agents have the longest latency, whereas vesicants, nerve agents, and cyanide produce signs and symptoms within seconds.

19. A 44-year-old client has been exposed to severe amount of radiation after a leak in a reactor plant. When planning this client's care, the nurse should implement what action? A. The client should be scrubbed with alcohol and iodine. B. The client should be carefully protected from infection. C. The client's immunization status should be promptly assessed. D. The client's body hair should be removed to prevent secondary contamination.

B. The client should be carefully protected from infection. Rationale: Damage to the hematopoietic system following radiation exposure creates a serious risk for infection. There is no need to remove the client's hair and the client's immunization status is not significant. Alcohol and iodine are ineffective against radiation.

31. A nurse who is a member of the local disaster response team is learning about blast injuries. The nurse should plan for what event that occurs in the tertiary phase of the blast injury? A. Victims' preexisting medical conditions are exacerbated. B. Victims are thrown by the pressure wave. C. Victims experience burns from the blast. D. Victims suffer injuries caused by debris or shrapnel from the blast

B. Victims are thrown by the pressure wave. Rationale: The tertiary phase of the blast injury results from the pressure wave that causes the victims to be thrown, resulting in traumatic injury. None of the other listed events occurs in this specific phase of a blast.

20. The nurse is coordinating the care of victims who arrive at the ED after a radiation leak at a nearby nuclear plant. What would be the first intervention initiated when victims arrive at the hospital? A. Administer prophylactic antibiotics. B. Survey the victims using a radiation survey meter. C. Irrigate victims' open wounds. D. Perform soap and water decontamination

B. Survey the victims using a radiation survey meter. Rationale: Each client arriving at the hospital should first be surveyed with the radiation survey meter for external contamination and then directed toward the decontamination area as needed. This survey should precede decontamination efforts or irrigation of wounds. Antibiotics are not indicated.

22. After radiation exposure, a client has been assessed and determined to be a possible survivor. Following the resolution of the client's initial symptoms, the care team should anticipate what event? A. A return to full health B. Internal bleeding C. A latent phase D. Massive tissue necrosis

C. A latent phase Rationale: A latent phase commonly follows the prodromal phase of radiation exposure. The client is deemed a possible survivor, not a probable survivor, so an immediate return to health is unlikely. However, internal bleeding and massive tissue necrosis would not be expected in a client categorized as a possible survivor.

33. A client has been admitted to the medical unit with signs and symptoms that are suggestive of anthrax infection. The nurse should anticipate what intervention? A. Administration of acyclovir B. Hematopoietic stem cell transplantation (HSCT) C. Administration of penicillin D. Hemodialysis

C. Administration of penicillin Rationale: Anthrax infection is treated with penicillin. Acyclovir is ineffective because anthrax is a bacterium. Dialysis and HSCT are not indicated.

8. While developing an emergency operations plan (EOP), the committee is discussing the components of the EOP. During the post-incident response of an emergency operations plan, what activity should take place? A. Deciding when the facility will go from disaster response to daily activities B. Conducting practice drills for the community and facility C. Conducting a critique and debriefing for all involved in the incident D. Replacing the resources in the facility

C. Conducting a critique and debriefing for all involved in the incident Rationale: A post-incident response includes critiquing and debriefing all parties involved immediately and at later dates. It does not include the decision to go from disaster response to daily activities; it does not include practice drills; and it does not include replacement of resources in the facility.

32. A client suffering from blast lung has been admitted to the hospital and is exhibiting signs and symptoms of an air embolus. What is the nurse's most appropriate action? A. Place the client in the Trendelenburg position. B. Assess the client's airway and begin chest compressions. C. Position the client in the prone, left lateral position. D. Encourage the client to perform deep breathing and coughing exercises

C. Position the client in the prone, left lateral position. Rationale: In the event of an air embolus, the client should be placed immediately in the prone left lateral position to prevent migration of the embolus and will require emergent treatment in a hyperbaric chamber. Chest compressions, deep breathing, and coughing would exacerbate the client's condition. Trendelenburg positioning is not recommended.

10. A group of disaster survivors is working with the critical incident stress management (CISM) team. Members of this team should be guided by what goal? A. Determining whether the incident was managed effectively B. Educating survivors on potential coping strategies for future disasters C. Providing individuals with education about recognizing stress reactions D. Determining if individuals responded appropriately during the incident

C. Providing individuals with education about recognizing stress reactions Rationale: In defusing, clients are given information about recognizing stress reactions and how to deal with handling the stress they may experience. Debriefing involves asking clients about their current emotional coping and symptoms, following up, and identifying clients who require further assessment and assistance in dealing with the stress experienced. The CISM team does not focus primarily on the management of the incident or on providing skills for future incidents.

14. A military nurse is treating a soldier after an unexploded ordnance (UXO) was purposely detonated for disposal. The blast radius was larger than anticipated and debris injured the soldier. The nurse anticipates what phase of blast injury occurred to this soldier? A. Primary B. Quaternary C. Secondary D. Tertiary

C. Secondary Rationale: A blast may result from terrorism but can also occur anywhere at any time if the right (or wrong) circumstances come together. Secondary blast injuries result from debris from the scene or shrapnel from the bomb that act as projectiles. These injuries may penetrate the trunk, skin, and soft tissue. Secondary blast injuries can also result in fractures and traumatic amputations. A blast injury has both direct and indirect consequences to the body. Identifying the phase of blast injury can help predict needed interventions more effectively and quickly. Primary, quaternary, and tertiary blast injuries are not the result of debris hitting the body. Primary blast injuries occur from the initial blast or air wave, and primarily affect air-filled organs. Quaternary blast injuries occur from pre-existing conditions that are exacerbated by the force of the blast or postblast injury complications. Common pre-existing conditions that can be worsened by blasts include asthma, chronic obstructive pulmonary disease (COPD), cardiac conditions, diabetes, and hypertension, whereas postblast injury complications occur from severe injuries with complex injury patterns such as burns, crush injuries, and head injuries. Tertiary blast injuries occur from the pressure wave that cause victims to be thrown, and often result in head injuries and fractures.

40. A nurse is giving an educational class to members of the local disaster team. What should the nurse instruct members of the disaster team to do in a chemical bioterrorist attack? A. Cover their eyes. B. Put on a personal protective equipment mask. C. Stand up. D. Crawl to an exit

C. Stand up. Rationale: Most chemicals are heavier than air, except for hydrogen cyanide. Therefore, in the presence of most chemicals, people should stand up to avoid heavy exposure because the chemical will sink toward the floor or ground. For this reason, covering their eyes, putting on a PPE mask, or crawling to an exit will not decrease exposure.

36. A nurse has had contact with a client who developed smallpox and became febrile after a terrorist attack. This nurse will require what treatment? A. Watchful waiting B. Treatment with colony-stimulating factors (CSFs) C. Vaccination D. Treatment with ceftriaxone

C. Vaccination Rationale: All people who have had household or face-to-face contact with a client with smallpox after the fever begins should be vaccinated within 4 days to prevent infection

6. When assessing clients who are victims of a chemical agent attack, the nurse is aware that assessment findings vary based on the type of chemical agent. The chemical sulfur mustard is an example of what type of chemical warfare agent? A. Nerve agent B. Blood agent C. Pulmonary agent D. Vesicant

D. Vesicant Rationale: Sulfur mustard is a vesicant chemical that causes blistering and results in burning, conjunctivitis, bronchitis, pneumonia, hematopoietic suppression, and death. Nerve agents include sarin, soman, tabun, VX, and organophosphates (pesticides). Hydrogen cyanide is a blood agent that has a direct effect on cellular metabolism, resulting in asphyxiation through alterations in hemoglobin. Chlorine is a pulmonary agent, which destroys the pulmonary membrane that separates the alveolus from the capillary bed.

37. The emergency response team is dealing with a radiation leak at the hospital. What action should be performed to prevent the spread of the contaminants? A. Floors must be scrubbed with undiluted bleach. B. Waste must be promptly incinerated. C. The ventilation system should be deactivated. D. Air ducts and vents should be sealed

D. Air ducts and vents should be sealed Rationale: All air ducts and vents must be sealed to prevent spread. Waste is controlled through double-bagging and the use of plastic-lined containers outside of the facility rather than incineration. Bleach would be ineffective against radiation and the ventilation system may or may not be deactivated.

11. Level C personal protective equipment has been deemed necessary in the response to an unknown substance. The nurse is aware that what piece of equipment or clothing will be included? A. A self-contained breathing apparatus B. A vapor-tight, chemical-resistant suit C. A uniform only D. An air-purified respirator

D. An air-purified respirator Rationale: Level C incorporates the use of an air-purified respirator, a chemical resistant coverall with splash hood, chemical-resistant gloves, and boots. Level A provides the highest level of respiratory, mucous membrane, skin, and eye protection, incorporating a vapor-tight, chemical-resistant suit and self-contained breathing apparatus (SCBA). Level B personal protective equipment provides the highest level of respiratory protection, with a lesser level of skin and eye protection, incorporating a chemical-resistant suit and SCBA. Level D is the same as a work uniform.

5. A client who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments? A. Integumentary assessment B. Assessment for signs of hemorrhage C. Neurologic assessment D. Assessment of respiratory status

D. Assessment of respiratory status Rationale: The second stage of anthrax infection by inhalation includes severe respiratory distress, including stridor, cyanosis, hypoxia, diaphoresis, hypotension, and shock. The first stage includes flu-like symptoms. The second stage of infection by inhalation does not include headache, vomiting, or syncope.

16. A client is admitted to the ED who has been exposed to a nerve agent. The nurse should anticipate the STAT administration of what drug? A. Amyl nitrate B. Dimercaprol C. Erythromycin D. Atropine

D. Atropine Rationale: Atropine is administered when a client is exposed to a nerve agent. Exposure to blood agents, such as cyanide, requires treatment with amyl nitrate, sodium nitrite, and sodium thiosulfate. Dimercaprol is administered IV for systemic toxicity and topically for skin lesions when exposed to vesicants. Erythromycin is an antibiotic, which is ineffective against nerve agents.

3. A client has been witness to a disaster involving a large number of injuries. The client appears upset, but states feeling capable of dealing with the emotions involved. What is the nurse's most appropriate intervention? A. Educate the client about the potential harm in denying their emotions. B. Refer the client to social work or spiritual care. C. Encourage the client to take a leave of absence from their job to facilitate emotional healing. D. Encourage the client to return to normal social roles when appropriate

D. Encourage the client to return to normal social roles when appropriate Rationale: The client should be encouraged to return to normal social roles when appropriate if confident and genuinely able to cope. The nurse should use active listening to the client's concerns and emotions to enable the client to process the situation. The client is not necessarily being unrealistic or dishonest. As a result, social work or spiritual care may not be needed. Time away from work may not be required.

29. The nurse has been notified that the ED is expecting terrorist attack victims and that level D personal protective equipment (PPE) is appropriate. What does level D PPE include? A. A chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots B. A self-contained breathing apparatus (SCBA) and a fully encapsulating, vapor-tight, chemical-resistant suit with chemical-resistant gloves and boots C. The SCBA and a chemical-resistant suit, but the suit is not vapor tight D. The nurse's typical work uniform

D. The nurse's typical work uniform Rationale: The typical work uniform is appropriate for Level D protection

30. The nurse is preparing to admit clients who have been the victim of a blast injury. The nurse should expect to treat a large number of clients who have experienced what type of injury? A. Chemical burns B. Spinal cord injury C. Meningeal tears D. Tympanic membrane rupture

D. Tympanic membrane rupture Rationale: Tympanic membrane (TM) rupture is the most frequent injury after subjection to a pressure wave resulting from a blast injury because the TM is the body's most sensitive organ to pressure. In most cases, other injuries such as meningeal tears, spinal cord injury, and chemical injuries are likely to be less common.

2. A workplace explosion has left a 40-year-old client with full thickness burns over 75% of the body. Despite these injuries, the client is conscious. How would this person be triaged? A. Green B. Yellow C. Red D. Black

D. Black Rationale: The purpose of triaging in a disaster is to do the greatest good for the greatest number of people. The client would be triaged as black due to the unlikelihood of survival. Persons triaged as green, yellow, or red have a higher chance of recovery.

17. A client was exposed to a dose of more than 5,000 rads of radiation during a terrorist attack. The client's skin will eventually show what manifestation? A. Erythema B. Ecchymosis C. Desquamation D. Necrosis

D. Necrosis Rationale: Necrosis of the skin will become evident within a few days to months at doses of more than 5,000 rads. With 600 to 1,000 rads, erythema will occur; it can disappear within hours and then reappear. At greater than 1,000 rads, desquamation (radiation dermatitis) of the skin will occur. Ecchymosis does not occur.