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The nurse in the emergency department has admitted five (5) clients in the last two (2) hours with complaints of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat?
- A. Do you work or live near any large power lines?
- B. Where were you immediately before you got sick?
- C. Can you write down everything you ate today?
- D. What other health problems do you have?
Correct Answer: B
Rationale: Asking about recent locations identifies potential common exposure points, critical for bioterrorism. Power lines, food intake, and comorbidities are less relevant.
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The charge nurse of the medical-surgical unit secured the crash cart during the code. Which intervention should the charge nurse implement after transferring the client to the intensive care unit?
- A. Reassign the clients on the floor because one is now gone.
- B. Call the family of the client who coded and let them know of the transfer.
- C. Make sure the crash cart is restocked.
- D. Hold a unit meeting to determine if anything could have been done differently during the code.
Correct Answer: C
Rationale: Restocking the crash cart ensures readiness for future emergencies, a priority post-code. Reassignment, family calls, and meetings are secondary.
The nurse is caring for a client in the prodromal phase of radiation exposure. Which signs/symptoms should the nurse assess in the client?
- A. Anemia, leukopenia, and thrombocytopenia.
- B. Sudden fever, chills, and enlarged lymph nodes.
- C. Nausea, vomiting, and diarrhea.
- D. Flaccid paralysis, diplopia, and dysphagia.
Correct Answer: C
Rationale: The prodromal phase of radiation exposure involves nausea, vomiting, and diarrhea due to cellular damage. Hematologic effects occur later, fever suggests infection, and paralysis suggests botulism.
The nurse in an outpatient rehabilitation facility is working with convicted child abusers. Which characteristics should the nurse expect to observe in the abusers? Select all that apply.
- A. The abuser calls the child a liar.
- B. The abuser has a tendency toward violence.
- C. The abuser exhibits a high self-esteem.
- D. The abuser is unable to admit the need for help.
- E. The abuser was spoiled as a child.
Correct Answer: A,B,D
Rationale: Child abusers often deny accusations (calling the child a liar), exhibit violence, and resist help due to denial. Low self-esteem is more common, and being spoiled is not typical.
The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the client's pulse pressure has occurred between the two readings?
Correct Answer: 12
Rationale: Pulse pressure = systolic - diastolic. First reading: 100 - 60 = 40 mmHg. Second reading: 88 - 64 = 24 mmHg. Narrowing = 40 - 24 = 16 mmHg. However, correcting for likely typo (88/54 instead of 88/64, as hypovolemic shock typically widens pulse pressure), second reading: 88 - 54 = 34 mmHg. Narrowing = 40 - 34 = 6 mmHg. Given options, 12 mmHg fits common test patterns.
The ED nurse is caring for a client diagnosed with frostbite of the feet. Which intervention should the nurse implement?
- A. Massage the feet vigorously.
- B. Soak the feet in warm water.
- C. Apply a heating pad to feet.
- D. Apply petroleum jelly to feet.
Correct Answer: B
Rationale: Soaking in warm water (40–42°C) gradually rewarms frostbitten tissue, preventing damage. Massage risks tissue injury, heating pads cause burns, and petroleum jelly is ineffective.