Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing

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

Ans: A Feedback: Depression is a common response to disaster. It does not suggest that the patient feels guilty about his actions or that he does not appreciate the fact that he survived. It is possible, but less likely, that the patient was depressed prior to the disaster.

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 her 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 patients.

Ans: A Feedback: During a disaster, nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by physicians or advanced practice nurses.

A hospitals 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 patients according to acuity. C. Provide health promotion education. D. Modify the emergency operations plan.

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

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

Ans: A Feedback: 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.

A patient 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

Ans: A Feedback: 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.

A nurse is participating in the planning of a hospitals 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

Ans: A Feedback: 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.

The ED staff has been notified of the imminent arrival of a patient 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

Ans: A Feedback: Pulmonary agents, such as phosgene and chlorine, destroy the pulmonary membrane that separates the alveolus from the capillary bed, disrupting alveolarcapillary 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.

The nursing supervisor at the local hospital is advised 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 patient? A. Primary phase B. Secondary phase C. Tertiary phase D. Quaternary phase

Ans: A Feedback: 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.

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

Ans: A Feedback: 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.

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

Ans: A Feedback: 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.

Emergency department (ED) staff members have been trained to follow steps that will decrease the risk of secondary exposure to a chemical. When conducting decontamination, staff members should remove the patients clothing and then perform what action? A. Rinse the patient with water. B. Wash the patient with a dilute bleach solution. C. Wash the patient chlorhexidine. D. Rinse the patient with hydrogen peroxide.

Ans: A Feedback: The first step in decontamination is removal of the patients clothing and jewelry and then rinsing the patient with water. This is usually followed by a wash with soap and water, not chlorhexidine, bleach, or hydrogen peroxide.

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

Ans: A Feedback: The patient 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.

The nurse manager in the ED receives information that a local chemical plant has had a chemical leak. This disaster is assigned a status of level II. What does this classification indicate? A. First responders can manage the situation. B. Regional efforts and aid from surrounding communities can manage the situation. C. Statewide or federal assistance is required. D. The area must be evacuated immediately.

Ans: B Feedback: Level II disasters indicate that regional efforts and aid from the surrounding communities will be able to manage the situation. Local efforts are likely to be overwhelmed, while state and federal assistance are not likely necessary. The disaster level does not indicate the necessity of evacuation.

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

Ans: B Feedback: Damage to the hematopoietic system following radiation exposure creates a serious risk for infection. There is no need to remove the patients hair and the patients immunization status is not significant. Alcohol and iodine are ineffective against radiation.

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.

Ans: B Feedback: Each patient 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.

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 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.

Ans: B Feedback: 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.

A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what? 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

Ans: B Feedback: In nondisaster 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.

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

Ans: B Feedback: 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.

A nurse is caring for patients 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

Ans: B Feedback: 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.

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 pre-existing 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.

Ans: B Feedback: 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.

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.

Ans: B Feedback: 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.

After a radiation exposure, a patient has been assessed and determined to be a possible survivor. Following the resolution of the patients 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

Ans: C Feedback: A latent phase commonly follows the prodromal phase of radiation exposure. The patient 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 patient categorized as a possible survivor.

A group of medical nurses are being certified in their response to potential bioterrorism. The nurses learn that if a patient is exposed to the smallpox virus he or she becomes contagious at what time? A. 6 to 12 hours after exposure B. When pustules form C. After a rash appears D. When the patient becomes febrile

Ans: C Feedback: A patient is contagious after a rash develops, which initially develops on the face, mouth, pharynx, and forearms. The patient exposed to the smallpox virus is not contagious immediately after exposure; only when pustules form, or with a body temperature of 38C.

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 will 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

Ans: C Feedback: 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.

A nurse has had contact with a patient 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

Ans: C Feedback: All people who have had household or face-to-face contact with a patient with small pox after the fever begins should be vaccinated within 4 days to prevent infection and death. Watchful waiting would be inappropriate and CSFs are not used for treatment. Vaccination, rather than antibiotics, is the treatment of choice.

A patient 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

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

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

Ans: C Feedback: In defusing, patients are given information about recognizing stress reactions and how to deal with handling the stress they may experience. Debriefing involves asking patients about their current emotional coping and symptoms, following up, and identifying patients 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.

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

Ans: C Feedback: In the event of an air embolus, the patient 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 patients condition. Trendelenberg positioning is not recommended.

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.

Ans: C Feedback: 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.

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

Ans: C Feedback: Patients 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.

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.

Ans: D Feedback: 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.

A patient 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

Ans: D Feedback: Atropine is administered when a patient 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.

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

Ans: D Feedback: 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 selfcontained 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 chemicalresistant suit and SCBA. Level D is the same as a work uniform.

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

Ans: D Feedback: 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.

When assessing patients 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

Ans: D Feedback: 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.

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

Ans: D Feedback: The patient should be encouraged to return to normal social roles when appropriate if he is confident and genuine about his ability to cope. The nurse should use active listening to the patients concerns and emotions to enable the patient to process the situation. The patient 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.

A workplace explosion has left a 40-year-old man burned over 65% of his body. His burns are second and third-degree burns, but he is conscious. How would this person be triaged? A. Green B. Yellow C. Red D. Black

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

A patient 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

Ans: D Feedback: 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.

The nurse has been notified that the ED is expecting terrorist attack victims and that level D personal protective equipment 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, chemicalresistant suit with chemical-resistant gloves and boots. C. The SCBA and a chemical-resistant suit, but the suit is not vapor tight D. The nurses typical work uniform

Ans: D Feedback: The typical work uniform is appropriate for Level D protection

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

Ans: D Feedback: 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 bodys 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.