3421 Adults II - Emergency, Disaster, & Infection

The nurse is providing education to a client who has been diagnosed with chlamydia. The client will begin treatment with azithromycin today. Which teaching point should the nurse reinforce with this client? "It is very important to maintain good handwashing, even while you are being treated." "Abstain from any sexual activity for 1 week after the antibiotic is complete." "Coinfection with the herpes simplex virus is common with chlamydia." "If you become reinfected, symptoms will immediately be present."

"Abstain from any sexual activity for 1 week after the antibiotic is complete."

A client arrives at the emergency department and is experiencing a severe allergic reaction to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed? "I should always wear something on my feet when I'm outside." "Brightly colored clothes help to ward off bees." "If a bee comes near me, I should stay still." "I need to avoid using perfumes and scented soaps when I'm going outside."

"Brightly colored clothes help to ward off bees." This attracts bees.

A woman is brought to the emergency department by her husband, who reports that his wife "accidentally fell down a flight of steps and broke her arm." The patient is very quiet and withdrawn. During the examination, inspection reveals numerous bruises at different stages of healing over the patient's legs, arms, and abdomen. The nurse suspects abuse. Which of the following questions would be most appropriate for the nurse to use to gather additional information? "You have bruises all over your body. Your husband is beating you, isn't he?" "I've noticed several bruises here and there. Can you tell me what happened?" "Now tell me, did you really fall down the stairs like your husband said?" "Your husband has no right to do this to you. Do you want me to call the police?"

"I've noticed several bruises here and there. Can you tell me what happened?" Use a nonthreatening approach that allows the patient to feel comfortable and trusting of the nurse. Therapeutic communication techniques with skillful interviewing are key. Acknowledging the evidence of the bruises and then asking the patient about them is a broad opening statement that allows the patient to direct the response. Do not accuse them of lying.

The nurse is talking to a client who has come to the doctor's office to ensure that the client's sexually transmitted infection (STI) has been successfully treated. Which statement by the client requires further instruction? "I'm glad that the health care practitioner checked me for STIs when I came for my regular checkup because I didn't have any symptoms." "I will plan to use a dental dam from now on whenever I engage in oral sex." "It's great that I don't have to worry about having this infection again because I'm now immune to it." "I realize that using a condom with a spermicide will eliminate most chances of getting any type of a sexually transmitted infection."

"It's great that I don't have to worry about having this infection again because I'm now immune to it."

The nurse is caring for a client in the ED following a sexual assault. The client is hysterical and crying. The client states, "I know I'm pregnant now, maybe I have HIV. Why did this happen to me?" Which is the best response by the nurse? "Let's talk about this. Do you want me to call a support person?" "Do you want to discuss antipregnancy measures?" "Do you want the phone number for the National Sexual Assault Hotline?" "Would you like us to complete HIV testing?"

"Let's talk about this. Do you want me to call a support person?" The goals of management are to provide support, reduce the client's emotional trauma, and gather available evidence for possible legal proceedings.

The nurse is providing education about treatment for syphilis to a client who has a confirmed infection. The client states, "Penicillin causes me to have raised, red bumps all over my body. Will I have to take it again?" How should the nurse respond? "You can be treated with an alternative antibiotic called doxycycline." "There are many alternatives to taking antibiotics to treat syphilis." "Ceftriaxone is an antibiotic that is also effective in the treatment of this infection." "Topical application of an immune response modifier can be used instead."

"You can be treated with an alternative antibiotic called doxycycline." Penicillin IM, Doxycycline, or Tetracycline

Permanent brain injury or death will occur within which time frame secondary to hypoxia? 1 to 2 minutes 3 to 5 minutes 6 to 8 minutes 9 to 10 minutes

3 to 5 minutes

The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action? Administer analgesic medications as ordered. Keep the hand in the circulating bath for 1 hour. Rupture any hemorrhagic blebs that are noted. Have the client complete active range-of-motion exercises.

Administer analgesic medications as ordered. Rewarming is painful (coming inside from the cold, ears and fingers can hurt to warm up and they're not even damaged) Warming bath should be done only 30-40min at a time

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.) Have the patient shower or wash the perineal area before the examination. Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Ensure that the police are present when the examination is performed.

Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police.

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? Attach a cardiac monitor Insert a Foley urinary catheter Assist with endotracheal intubation Administer inotropic drugs

Attach a cardiac monitor Cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation.

A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful? Brachial Femoral Radial Subclavian

Brachial Proximal to the bleeding site, reduces blood loss

The nurse is discussing childhood immunization recommendations with a pediatric patient's parent. Where would the nurse find the most current information on this topic? The World Health Organization The Joint Commission CDC The Occupational Safety Health Administration

CDC

A client is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action? Check the client's blood glucose level. Assess for a documented history of major depression. Determine whether the client has ingested a corrosive substance. Arrange for assessment of serum potassium levels.

Check the client's blood glucose level. Hypoglycemia can have some of the same symptoms (off balance, confused)

A client is admitted to the ED after being involved in a motor vehicle accident. The client has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care? Control the client's hemorrhage. Assess for cognitive effects of the injury. Splint the client's fractures. Assess the client's neurologic status.

Control the client's hemorrhage. Assessment is often first, but the patient will bleed out

During a mass disaster, the nurse is caring for a victim whose status has been categorized as yellow during triage. How should the nurse best allocate time and resources to this client's care? Forego immediate care because the client is unlikely to survive Place a low priority on the client's care because the client will likely recover independently Provide high-priority, immediate care to save the client's life Delay the client's treatment for a few hours if other clients need immediate care

Delay the client's treatment for a few hours if other clients need immediate care

The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? Diagnostic and laboratory testing Assessment of peripheral pulses Establishing a patent airway Undressing the client

Diagnostic and laboratory testing Airway, cardiovascular assessment, and undressing are all primary survey. Secondary survey is diagnostics, labs, head to toe assessment, monitoring devices, splinting, and tending wounds.

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? Actively listening to the victims' concerns. Encouraging the victims to watch television replays of the event. Referring victims to appropriate social service agencies. Encouraging victims to return to normal activities as they feel ready.

Encouraging the victims to watch television replays of the event. Retraumatizing

In which triage category would the nurse include a client who requires simple first aid or basic primary care? Urgent Fast track Nonurgent Emergent

Fast track Fast-track clients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office.

A client is brought to the ED by family members who tell the nurse that the client has been exhibiting paranoid, agitated behavior. What should the nurse do when interacting with this client? Keep the client in a confined space. Use therapeutic touch appropriately. Give the client honest answers about likely treatment. Attempt to convince the client that his or her fears are unfounded.

Give the client honest answers about likely treatment. Foster rapport and trust, don't stress them further

The nurse is assessing a client in the emergency department who grimaces and reports swelling of the testicles, burning on urination and a green discharge from the penis. The nurse suspects the client will be diagnosed with which infection? Gonorrhea Primary syphilis Herpes genitalis Trichomoniasis

Gonorrhea

The nurse is caring for a victim of a sexual assault. The client is fearful and experiencing flashbacks. The nurse recognizes that the client is experiencing which phase of the psychological reaction to rape? Heightened anxiety phase Acute disorganization phase Denial phase Reorganization phase

Heightened anxiety phase Heightened anxiety phase = client demonstrates anxiety, hyperalertness, psychosomatic reactions, fear, and flashbacks. Acute disorganization phase = shock, disbelief, guilt, humiliation, and anger. Denial phase = an unwillingness to talk. Reorganization phase occurs when the incident is put into perspective.

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following? Forceful coughing Wheezing between coughs High-pitched noise on inhalation Refusal to lie flat

High-pitched noise on inhalation Think strider

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? Anaphylaxis Sepsis Hypovolemia Cardiac dysfunction

Hypovolemia

A nurse is providing care to a client who has been exposed to phosgene vapor. Which nursing diagnosis would the nurse identify as the priority? Impaired gas exchange related to destruction of the pulmonary membrane Impaired skin integrity related to vesicant contact with skin Disturbed sensory perception: visual related to bilateral miosis and visual disturbances Decreased cardiac output related to altered aerobic metabolism from agent exposure

Impaired gas exchange related to destruction of the pulmonary membrane

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? Possible Probable Likely Improbable

Improbable Improbable survivors have received more than 800 rad of total-body penetrating irradiation, they demonstrate an acute onset of vomiting, bloody diarrhea, and shock. Any neurologic symptoms suggest a lethal dose of radiation. Possible survivors present with nausea and vomiting that persist for 24 to 48 hours. Probable survivors have either no initial symptoms or only minimal symptoms (e.g., nausea and vomiting), or these symptoms resolve within a few hours. "Likely" is not a survival category.

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? Dilution with water or milk Gastric lavage Administration of activated charcoal Induced vomiting

Induced vomiting Don't put the caustic substance back in the delicate throat tissue

The nurse is completing the admission assessment on a client with renal failure. The client states, "I was diagnosed with impetigo yesterday." Which is the appropriate nursing intervention? Obtain the name of the antiviral medication used to treat the impetigo. Initiate contact isolation protocol. Transfer the client to a negative-pressure room. Educate the client about wearing a mask outside of the assigned room.

Initiate contact isolation protocol. Bacterial infection on skin, not airborne

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? Providing an analgesic for pain Massaging the feet Restricting ambulation Placing sterile cotton between the toes after rewarming

Massaging the feet Don't release blood clots into the bv's.

A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority? Monitor vital signs and oxygen saturation every 15 to 30 minutes. Suction the client as needed to obtain a sputum specimen for culture and sensitivity. Assess intake and output and maintain adequate hydration. Reassure the client that intubation and mechanical ventilation will be temporary.

Monitor vital signs and oxygen saturation every 15 to 30 minutes. Assessing the client for changes in his respiratory status takes priority

Which medication reverses severe respiratory depression and coma? Naloxone hydrochloride Diazepam Flumazenil N-acetylcysteine

Naloxone hydrochloride

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? Vesicant Nerve agent Blood agent Pulmonary agent

Nerve agent The client was working with pesticides, organophosphates, which are considered nerve agents. The client's signs and symptoms also reflect exposure to a nerve agent.

Three victims of radiation exposure are brought into the Emergency Department. As the nurse caring for these clients, you would expect what substance to be ordered to reduce radiologic organ damage? Cyan red Potassium iodide Russian blue Medical iodine

Potassium iodide Potassium iodide, Prussian blue, and diethylenetriamine pentaacetate can prevent or reduce radiologic organ damage. Medical iodine is used to cleanse skin. "Cyan red" means blue red, it's fake. Prussian, not Russian blue.

The nurse is working in the labor and delivery suite when a client with active herpes simplex virus type 2 (HSV-2) appears in active labor. Which adjustment in the plan of care will the nurse prepare for? Administer an intravenous antibiotic to the mom while in labor. Complete a full assessment of the newborn on delivery. Prepare for a cesarean section. Place an antibacterial ointment on the mother's lesions.

Prepare for a cesarean section.

Several patients that have been involved in a bombing are unlikely to survive. What priority are these patients given during triage? Priority 1 Priority 2 Priority 3 Priority 4

Priority 4 Expectant

The nurse is providing care for a client who was admitted to the intensive care unit after suffering cardiovascular collapse secondary to a methamphetamine overdose. The client is semi-conscious and has a nasopharyngeal in place. The nurse anticipates this client may require which interventions? Select all that apply. Provide airway support and ventilation Minimize lights and noise disturbances Apply warming blankets Administer antipsychotic medication Follow the unit seizure protocol

Provide airway support and ventilation Minimize lights and noise disturbances Administer antipsychotic medication Follow the unit seizure protocol Due to the hallucinations and/or delusions that can be caused by the illicit substance overdose, the client may require antipsychotic medication such as haloperidol. Clients can experience seizures after illicit substance overdose and withdrawal.

Exposure to gamma radiation can be decreased by completing which action? Wearing thick clothes Lengthening the duration of exposure Providing distance from radiation source Providing plastic shielding

Providing distance from radiation source

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? Pulmonary edema Pneumonia Congestive heart failure Panic attack

Pulmonary edema

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 Chemical Biologic Manmade

Radiologic

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? Neurological compromise Respiratory compromise Cardiovascular compromise Sensory neglect

Respiratory compromise A person exposed to a blistering agent or vesicant must be decontaminated immediately, with clothing removed and bagged. Irrigation of the victim's eyes and application of topical analgesia, antibiotics, and lubricants to the skin occur. Simultaneously, the nurse is assessing the respiratory system for airway obstruction because blisters from inhaled toxics can swell obstructing respiratory passages.

A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn? Applying antimicrobial ointment Administering tetanus prophylaxis Covering the area with a sterile dressing Rinsing the area with copious amounts of water

Rinsing the area with copious amounts of water The priority for any chemical burn is to immediately drench the area with running water, unless the chemical is lye or white phosphorus, which should be brushed off the patient. All labs have showers and eyewash stations

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action? Remove the peripheral IV line Start a dextrose 5% water infusion Run a normal saline line to keep the vein open Obtain a blood culture from the IV insertion site

Run a normal saline line to keep the vein open Be ready to treat the transfusion rxn

The Department of Homeland Security indicates a threat level "Imminent" relative to a situation. What does the nurse know that this indicates? Elevated risk of attack Severe, credible impending threat, usually with a site specified Risk of attack, without a site specified Risk of attack, without timing specified

Severe, credible impending threat, usually with a site specified

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)? Acyclovir is effective against smallpox. Smallpox is spread by inhalation of spores. A vaccination is effective only if administered within 12 to 24 hours of exposure. Smallpox spreads rapidly and requires immediate isolation.

Smallpox spreads rapidly and requires immediate isolation. There is no effective antiviral for smallpox, just vaccination. Highly contagious.

A client has been exposed to a vesicant and is undergoing decontamination. Which of the following most likely would be used? Sodium hypochlorite Soap and water Alcohol Chlorhexidine

Soap and water Remove the vesicant from the skin, sodium hypochlorite solutions are avoided because they increase penetration of the nerve agent.

A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound? Laceration Avulsion Stab Patterned

Stab

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? Stage I Stage II Stage III Stage IV

Stage III Stage I presents with a classic "bull's-eye" rash (erythema migrans) and flulike signs and symptoms. If untreated, stage II Lyme disease may present within 4 to 10 weeks laterand may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin weeks or over a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis. There is no stage IV.

Which organism is responsible for impetigo? Histoplasma capsulatum Bacillus anthracis Clostridium difficile Staphylococcus aureus

Staphylococcus aureus

A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? Collecting semen Performing the pelvic examination Obtaining consent for examination Supporting the client's emotional status

Supporting the client's emotional status Priority is taking care of the client. The rest is up to them if they want to proceed, and shouldn't be done if they are not emotionally supported.

When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind? The client is assumed to have a spinal cord injury until proven otherwise. The most lethal injuries are often the most readily apparent. Most multiple trauma victims exhibit evidence of the trauma. Injuries have occurred to at least three distinct organ systems.

The client is assumed to have a spinal cord injury until proven otherwise.

When a hospitalized client is in contact precautions, which action is necessary? The client's door should be closed. Masks should be worn when caring for the client. The client should be placed in a private room when possible. The client should be in a room with negative air pressure.

The client should be placed in a private room when possible.

You are an Emergency Department nurse who has to care for three victims of anthrax. The first victim inhaled the toxin, the second victim ingested it, and the third victim suffered a skin infection. Which client should be cared for first? The one who ingested the toxin The one who inhaled the toxin The one with the skin infection Any convenient order

The one who inhaled the toxin Inhaled is the most serious form of anthrax, could have RD

What is a common source of airway obstruction in an unconscious client? A foreign object Saliva or mucus The tongue Edema

The tongue In an unconscious client, the muscles controlling the tongue can relax, causing the tongue to obstruct the airway. The nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If they suspect the client has a neck injury they must perform the jaw-thrust maneuver.

Which is defined as the potential of an agent to cause injury to the body? Volatility Latency Persistence Toxicity

Toxicity

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? Blast lung Tympanic rupture Head injury Abdominal injury

Tympanic rupture

After demonstrating to a group of nursing students the proper technique for handwashing using soap and water, the nursing instructor determines that the teaching has been successful when the students demonstrate which of the following? Washing the hands for 5 to 10 seconds Vigorously scrubbing between the fingers Removing the soap with a paper towel before rinsing Washing underneath artificial fingernails

Vigorously scrubbing between the fingers "YoU cAnT hAvE yOuR nAiLs DoNe"

The nurse is caring for a client with secondary syphilis. What intervention should the nurse institute when caring for this client? Ensure that the client is housed in a private room. Administer hydrocortisone ointment to the lesions as prescribed. Administer combination therapy with antiretrovirals as prescribed. Wear gloves if contact with lesions is possible.

Wear gloves if contact with lesions is possible. Lesions are highly infective, just contact precautions

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 red green black

Yellow Not hitting a vital organ, I guess, okay to wait 6-8hrs

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: blood pressure. hemoglobin level. temperature. heart rate.

blood pressure

A nuclear accident (intentional or unintentional) can cause significant harm to those living nearby or at a distance. Harmful levels of invisible gamma radiation penetrate the body, not only causing devastating injuries but possibly contaminating others. What type of transmission precaution prevents such person-to-person contamination? contact airborne droplet standard

contact Invisible gamma radiation penetrates the body and can be eliminated in blood, sweat, urine, and feces. Consequently, a contaminated person can contaminate others through contact with body fluids or surfaces he or she touches.

The six elements necessary for infection include a causative organism, a reservoir of available organisms, a portal or mode of exit from the reservoir, a mode of transmission from reservoir to host, a susceptible host, and: mode of exit from the host. virulent host. mode of entry into the host. latent time period.

mode of entry into the host.

The first step in decontamination includes: thoroughly washing the client with soap and water and then rinsing. removing the client's clothing and jewelry and then rinsing the client with water. immediately applying personal protective equipment to the client. immediately applying chemical decontamination foam to the area of contamination.

removing the client's clothing and jewelry and then rinsing the client with water.