Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing

As a member of a disaster response team that is responding to a large industrial fire that may involve chemical exposure, a nurse is gathering information from several bystanders. Which statement would lead the nurse to suspect that cyanide is involved?

"The air had a strange smell of bitter almonds."

The nurse is developing a plan of care for clients exposed to radiation during a mass casualty incident. The nurse assesses the onset of gastrointestinal symptoms such as nausea, vomiting, loss of appetite, diarrhea, and/or fatigue within how many hours after exposure?

48 to 72

Prophylaxis antibiotic for anthrax is given to people with symptoms who have been in a defined "hot zone" for which time frame?

60 days

The nurse is caring for three clients who have been diagnosed with anthrax. They were exposed after boarding a flight where a white powdery substance was found in one of the restrooms. The nurse knows that these clients would be classed as being victims of which of the following?

A biologic disaster

One of the nuclear power plants experiences a crack in the protection of the core when the cooling system malfunctions. The thought is that the cooling system was tampered with. Healthcare facilities in the area are inundated with victims residing in the area around the power plant. What category of disaster would this be?

A radiologic disaster

The nurse is caring for a client affected by a nerve agent. The nurse quickly gives a tutorial on the neurotransmitters and nervous system affected. Which couplet is most correct?

Acetylcholine, parasympathetic nervous system

When working in an acute care facility as part of a disaster response team, a nurse is preparing to care for clients requiring level C protection. Which of the following would the nurse need to wear?

Air-purified respirator Explanation: Level C protection requires an air-purified respirator, a chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots. Level A protection requrie a self-contained breathing apparatus and a fully encapsulating, vapor-tight chemical-resistant suit with chemical-resistant gloves and boots. Level D protection requires the use of the typical work uniform.

Which is the most likely weaponized biological agent available?

Anthrax

The nurse is caring for a client diagnosed with botulism. Which medication classification does the nurse anticipate?

Antitoxins

A nurse is preparing an in-service education program to a group of nurses who are members of a disaster response team specializing in biologic weapons. Which of the following would the nurse include as the agent of choice when dealing with a mass casualty incident involving anthrax?

Ciprofloxacin

The nurse is caring for a victim of a chemical disaster. Medications given in the treatment of this client include amyl nitrite, sodium nitrite, and sodium thiosulphate. What chemical agent does the nurse know this client has been exposed to?

Cyanide

A nurse who was working as part of an emergency response team for a mass casualty incident is engaging in a Critical Incident Stress Management program. The nurse has received information about how to recognize stress reactions and ways to manage them. The nurse is involved in which of the following?

Defusing

Which term refers to a process by which an individual receives education about recognition of stress reactions and management strategies?

Defusing

The nurse is working at a natural disaster scene. A client was found to have a compound fracture of the left lower leg. He was triaged accordingly. Which category would the client be assigned to?

Delayed

Which of the following would the nurse expect to assess in a client who has inhaled Clostridium botulinum? Select all that apply.

Diplopia Dysphagia Fever Dry mouth

You are caring for radiation victims. What is the most important factor that you should consider to assess a client's chance of survival in acute radiation syndrome (ARS)?

Dosage of gamma radiation

A nurse is working with a group of disaster victims to reduce the psychological effects of the trauma. Which of the following would be least helpful?

Encouraging the victims to watch television replays of the event.

A public health nurse is presenting an educational event to the local disaster response team on radiation injury. The nurse describes a client whose burns and trauma are evident. What type of radiation injury is this?

External Explanation: External radiologic contamination occurs from exposure to fallout on the skin, hair, and clothing. Direct and indirect are distracors for this question. This does not describe a client with internal radiologic contamination.

Which is a true statement regarding severe acute respiratory syndrome (SARS)?

It is most contagious during the second week of illness.

A soldier is preparing to enter an area in which there is a high risk for chemical exposure to a nerve agent. What should the soldier be given prior to entering this area?

Mark I automatic injectors that contain 2 mg atropine and 600 mg pralidoxime chloride

Which chemical is a vesicant?

Nitrogen mustard

Which is a clinical manifestation of sulfur mustard?

Partial-thickness burns

Several patients that have been involved in a bombing are unlikely to survive. What priority are these patients given during triage?

Priority 4

While watching a television newscast, a nurse hears that the Department of Homeland Security has identified the security threat level as yellow. The nurse interprets to mean which of the following?

There is an elevated risk but no defined site.

A client who has been exposed to radiation develops acute radiation syndrome. It has been about 2 weeks since he initially showed signs and symptoms and the client is undergoing laboratory testing. Which of the following would the nurse expect to find?

Thrombocytopenia

Which is defined as the potential of an agent to cause injury to the body?

Toxicity

The clinic nurse is triaging a client who had visited a smallpox affected community 14 days ago. The client has developed a fever but no rash. Should the nurse consider the client at risk for smallpox?

Yes, fever and rash may follow 14 asymptomatic days.

Often, treatments used for exposure to biologic agents manage the symptoms; the disease process must run its course. Which biologic agent exposure requires the use of ventilation support of breathing, possibly for up to 2 to 3 months?

botulism Explanation: Generally, initial treatment of botulism follows a clinical rather than a laboratory diagnosis. Tests on serum, gastric, and fecal specimens tend to be too time consuming to justify a delay in treatment. Mechanical ventilation is required to support breathing for 2 to 3 months.

Four clients injured in an automobile accident enter the emergency department at the same time. The triage nurse evaluates them immediately. The nurse should assign the highest priority to the client with the:

maxillofacial injury and gurgling respirations.

The nurse is assessing a victim who is reported to have been exposed to sulfur mustard. The nurse's assessment should include evaluation for

partial-thickness burns.

Following an explosion at a chemical plant, a nurse is triaging clients. One client has a penetrating abdominal wound from a piece of shrapnel. What color coordinate would the nurse assign to this client?

yellow Explanation: A yellow triage tag means the client is in serious condition yet stable enough to survive if treatment is delayed 6 to 8 hours. Red tags are assigned to life-threatening injuries that require immediate medical attention. Green tags indicate the client has minor injuries, such as minor lacerations or superficial burns. Black tags indicate the client is going to die soon and usually apply to serious head injuries or multisystem traumas.

Nursing students are reviewing information about weapons of terror. The students demonstrate understanding of the information when they identify which of the following as examples of chemical weapons? Select all that apply.

Cyanide Phosgene Sarin Explanation: Chemical weapons include cyanide (a blood agent), phosgene (a vesicant and pulmonary agent), and sarin (a nerve agent). Anthrax and tularemia are examples of biologic agents of terror.

The nurse is triaging victims after an explosion at an oil refinery. One victim reports tinnitus, dizziness, and otorrhea. For what probable condition should the nurse prepare care?

Tympanic rupture

To prepare the community for the possible threat of anthrax, a nurse must teach that:

anthrax can infect the integumentary, GI, and respiratory systems.

During a facility disaster drill, an "injured client" presents to the emergency department with complaints of dry mouth, inability to focus his vision, and double vision. A nurse notes that the client has an unsteady gait and appears to be very weak. The client states, "My arms and legs feel like they just can't move." A nurse suspects the client may be a victim of bioterrorism with:

botulism.

A nuclear reactor overheated, releasing radiation throughout the plant. A worker close to reactor received at least 800 rads and has had an onset of vomiting, bloody diarrhea, and, when brought to the hospital, was in shock. What is this patient's predicted survival?

Improbable

A client comes to the emergency department complaining of vision changes, nausea, vomiting, diarrhea, and tightness in the chest. The client reports that he was out on his farm spraying some pesticides. Based on the client's information, the nurse would suspect exposure to which of the following?

Nerve agent

Which statement reflects the nursing management of pulmonary anthrax (Bacillus anthracis)?

Treatment with ciprofloxacin or doxycycline is suggested after exposure.

A patient was brought into the ED after sustaining injuries due to an explosion while welding. The patient is breathing but has an oxygen saturation of 90%, a respiratory rate of 32, and is coughing. What is the priority action by the nurse?

Administer oxygen with a nonrebreather mask. Explanation: Blast lung results from the blast wave as it passes through air-filled lungs. The result is hemorrhage and tearing of the lung, ventilation-perfusion mismatch, and possible air emboli. Typical signs and symptoms include dyspnea, hypoxia, tachypnea or apnea (depending on severity), cough, chest pain, and hemodynamic instability. Management involves providing respiratory support that includes administration of supplemental oxygen with a nonrebreathing mask but may also require endotracheal intubation and mechanical ventilation.

The nurse is taking a class on chemical disasters with the local emergency response team. What toxins would the nurse be learning about? Select all that apply.

Blistering agents Nerve agents Cyanide

A patient was suspected of being in direct contact with anthrax but is exhibiting no signs or symptoms. What type of prophylaxis does the nurse know this patient will have to take?

Ciprofloxacin (Cipro) for 60 days

A nurse working as part of a disaster response team is triaging clients. Which of the following clients would the nurse color code as green? Select all that apply.

Client with a fractured arm Client with a first-degree burn to the forearm

A radiation disaster has occurred in the local community and clients are being transported to the nearby hospital. As part of the response team, an emergency department nurse is working to prepare the facility for the clients. As the clients arrive, which of the following would be done first?

Client would be checked with a meter for external contamination.

A patient was involved in an avalanche that killed many people on a ski trip, including the patient's brother. The nurse is educating the patient about recognition of stress reactions and ways to manage stress. What type of process is the nurse introducing to the patient?

Defusing Explanation: Components of a management plan include education (preparedness) before an incident occurs about critical incident stress and coping strategies; field support (ensuring that staff get adequate rest, food, and fluids, and rotating workloads) during an incident; and defusings, debriefings, demobilization, supportive services to the family, and follow-up care after the incident (Veenema, 2013). Defusing is a process by which the person receives education about recognition of stress reactions and management strategies for handling stress. Debriefing is a more complicated intervention; it involves a 2- to 3-hour process during which 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.

Which of the following federal disaster resources provides scene control and collection of forensic evidence?

Federal Bureau of Investigation (FBI)

Inhalation of anthrax mimics which disease process?

Flu

The nurse educator is preparing a presentation about the indicators of chemical terrorism. The nurse educator would include which indicators in the presentation. Select all that apply.

Fog-like or low-lying cloud in the atmosphere Numerous dead animals and birds Unexplained odor atypical for the location Explanation: The indicators that the nurse educator would include in the presentation are fog-like or low-lying cloud in the atmosphere, numerous dead animals and birds, and unexplained odor atypical for the location. The temperature in the area would not increase after a chemical event. There would be no wind associated with a chemical event.

A patient is being brought into the ED who is probably infected with anthrax. The nurse should ensure what level of personal protective equipment to wear for everyone who will come in contact with the patient?

Level D Explanation: Standard precautions are the only ones indicated to protect the caregiver exposed to a patient infected with anthrax. The patient is not contagious, and the disease cannot spread from person to person. Thus, only level D protection, the typical work uniform, is required.

A nurse is preparing to provide care to clients who are victims of an earthquake. Which of the following would the nurse identify as a factor that would least likely affect the emergency response?

Loss of building structures Explanation: In the event of a natural disaster, loss of communications, potable water, and electricity is usualy the greatest obstacle to a well-coordinated emergency response. Loss of building structures could increase the risk to emergency response personnel but they would have the least effects on the emergency response.

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injury?

Minor; treatment can be delayed hours to days

A nurse is providing care to a client who was exposed to a nerve agent. Which of the following would the nurse most likely assess?

Miosis Explanation: Exposure to a nerve agent manifests with signs and symptoms of cholinergic crisis including bilateral miosis, increased gastrointestinal motility, nausea, vomiting, diarrhea, substernal spasm, indigestion, bradycardia, bronchoconstriction, laryngeal spasm, weakness, fasciculations, and incontinence. Bullae are seen with vesicants.

The nursing instructor is talking with their students about botulism. The instructor tells the students that when caring for a client with botulism what condition is most likely to cause death?

Paralysis of respiratory muscles

A nurse is providing care to clients who were involved in an explosion and have sustained secondary blast injuries. Which types of injuries would the nurse expect to find? Select all that apply.

Pentetrating trauma Traumatic amputations

The nurse is caring for victims after a mass casualty incident with high-dosage radiation exposure. The victims are experiencing fever, respiratory distress, and increased excitability. The nurse documents that the victims are in which phase of radiation exposure?

Prodromal Explanation: The nurse documents that the victims are in the prodromal phase. In this phase, symptoms present 48 to 72 hours after exposure and include fever, respiratory distress, and increased excitability for victims exposed to high doses of radiation. During the latent phase, symptoms include decreasing numbers of lymphocytes, leukocytes, thrombocytes, and red blood cells.

A patient is suspected to have an air embolus after being in close proximity to an explosion at a sports arena. What position should the nurse place the patient in to prevent migration of the embolus?

Prone left lateral position Explanation: In the event of an air embolus, the patient should be immediately placed in the prone left lateral position to prevent migration of the embolus and will require emergent treatment in a hyperbaric chamber (CDC, 2013).

When describing the Emergency Operations Plan (EOP) to a group of nurses working as part of a disaster response team, which of the following would be identified as its primary goal?

Protection of the community

The nurse is reviewing information from a recent disaster management training session. The nurse knows that all of the following activities are part of the preparedness phase of disaster management except which of the following?

Provide emergency care Explanation: The preparedness phase of disaster management is the phase of planning for saving lives. Preparedness would include conducting training and mock disaster response drills, as well as designating location of shelters and developing early warning systems and evacuation routes. Providing emergency care is an aspect of the response phase. The purpose of the response phase is to limit injuries and deaths as well as reduce property damage.

Exposure to gamma radiation can be decreased by completing which action?

Providing distance from radiation source

Several families arrive at the scene of a disaster and are asking for information about their family members. Which person would be most appropriate to provide them with any information?

Public Information Officer

Homeland Security has alerted the disaster response teams in your region of a potential terrorist attack in the form of a nuclear blast. You are a part of the disaster response system and you know that with a nuclear blast you would need to be prepared for what classification of disaster?

Radiologic

A nurse who is working as part of a disaster response team is performing triage at a mass casualty incident. One of the victims has a sucking chest wound. The nurse would triage this client using which color-coded tag?

Red

The nurse receives a call from EMS personnel that they are bringing in eight patients who have been exposed to a chemical after a spill. The patients have been "washed off." After the initial assessment, what should be done?

Remove clothing and jewelry and rinse the patients off with water. Explanation: Decontamination must include a minimum of two steps. The first step is removal of the patient's clothing and jewelry and then rinsing the patient with water. Depending on the type of exposure, this step alone can remove a large amount of the contamination and decrease secondary contamination. The second step consists of a thorough soap-and-water wash and rinse. When patients arrive at the facility after being assessed and treated by a prehospital provider, it should not be assumed that they have been thoroughly decontaminated.

The emergency department nurse is caring for clients involved in a chlorine exposure accident at a local chemical plant. The nurse is aware that permanent damage can occur to which body systems?

Respiratory

The nurse is caring for a client exposed to a blistering agent. While the nurse is quickly decontaminating the client by showering and bagging all client clothing, what is the nurse simultaneously assessing for?

Respiratory compromise

A nursing instructor is reviewing the various security threat levels associated with the Department of Homeland Security. When describing the orange level, which of the following would the nurse include?

Security and screenings are increased.

The Department of Homeland Security indicates a threat level "Imminent" relative to a situation. What does the nurse know that this indicates?

Severe, credible impending threat, usually with a site specified

The nurse is evaluating a skin lesion on a client brought to the emergency department. The nurse notes characteristics of chickenpox but has the physician evaluate the lesion for which biologic disaster agent?

Smallpox

When preparing for an emergency bioterrorism drill, the nurse instructs the drill volunteers that each biological agent requires specific client management and medications to combat the virus, bacteria, or toxin. Which statement reflects the client management of variola virus (smallpox)?

Smallpox spreads rapidly and requires immediate isolation.

A client has been exposed to cyanide. Which of the following would the nurse expect to assist in administering? Select all that apply.

Sodium thiosulfate Sodium nitrite Amyl nitrate

A nurse is preparing a presentation to a local community group on disaster preparedness involving radiation exposure. Which of the following would the nurse least likely include when describing the factors that affect exposure?

Type of particle emitted

The student nurse is completing a simulation where a client is the victim of nerve gas. The instructions are for the student to set up the room and have all needed supplies available. Which medication does the student nurse ensure is in the medication administration system to control seizures?

Valium intravenous injection

Which term refers to the tendency for a chemical to become a vapor?

Volatility

You are part of a disaster response team. Your team has been activated, and you have just reported to your mobilization point. You are assigned to triage clients as they come in. What is the first act you should perform while assessing victims of a disaster?

Wear protective clothes

Although the thought of biologic disasters is alarming, treatment and transmission-based precautions can be relatively simple in some cases. Health care workers can protect themselves using standard precautions and treat clients using fluoroquinolone antibiotics for infections with which biologic agent?

anthrax Explanation: When anthrax is diagnosed by culturing blood, stool, and wound exudates, it is treated fairly successfully with antibiotic therapy. The preferred antibiotic is ciprofloxacin (Cipro) or levofloxacin (Levaquin), both of which are fluoroquinolones; the treatment lasts 4 weeks or longer for an inhalant infection. Botulinum antitoxin is the only immediate treatment after exposure to lessen the severity of botulism. No treatment currently exists for smallpox. Cyanide is a solid salt or volatile liquid chemical and not a biologic agent.

During a terrorist attack, multiple victims were exposed to nitrogen mustard. While caring for one of the victims admitted to the hospital, the nurse notes large, serous fluid-filled, circumscribed areas resembling a dome over the victim's axillae and antecubital spaces. The nurse should document this find as

bullae. Explanation: The nurse should document the large, serous fluid-filled, circumscribed areas as bullae. Papules are solid, elevated superficial lesions. Macules are flat circumscribed areas less than 1 cm in diameter. An abscess is a nodule/tumor greater than 1 cm that contains pus.

Man-made chemical disasters have been portrayed in movies and on television as nightmarish situations, at best. The most toxic chemical disasters are those caused by:

nerve agents. Explanation: Nerve agents, the most toxic of all chemical agents, are potent organophosphate compounds that cause fatal consequences by inhibiting acetyl cholinesterase, an enzyme that inactivates acetylcholine, a neurotransmitter of the parasympathetic (cholinergic) nervous system. Consequently, in cases of attacks with nerve agents, the functions of the parasympathetic nervous system will be active without any potential for disinhibition.