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Which situation requires the emergency department manager to schedule and conduct a Critical Incident Stress Management (CISM)?
- A. Caring for a two (2)-year-old child who died from severe physical abuse.
- B. Performing CPR on a middle-aged male executive who died.
- C. Responding to a 22-victim bus accident with no apparent fatalities.
- D. Being required to work 16 hours without taking a break.
Correct Answer: A
Rationale: CISM addresses emotional trauma, critical for staff after a child’s death from abuse. CPR death is routine, bus accidents without fatalities are less traumatic, and long hours are logistical.
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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.
The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death?
- A. Cardiac death occurs after being removed from a mechanical ventilator.
- B. Cardiac death is the time the HCP officially declares the client dead.
- C. Cardiac death occurs within one (1) hour of the onset of cardiovascular symptoms.
- D. The death is caused by myocardial ischemia resulting from coronary artery disease.
Correct Answer: C
Rationale: Sudden cardiac death is defined as death within 1 hour of cardiovascular symptoms, often due to arrhythmias. Ventilator removal, declaration time, and ischemia are related but not definitional.
The nurse is providing discharge teaching for the client with intermaxillary wiring to repair a fractured mandible. Which statement by the client indicates teaching has been effective?
- A. Iced alcoholic drinks may be consumed by using a straw.
- B. Only one (1) food item should be consumed at one (1) time.
- C. Carbonated sodas should be limited to two (2) daily.
- D. Teeth can be brushed after tenderness and edema subside.
Correct Answer: D
Rationale: Brushing teeth after swelling subsides maintains oral hygiene safely. Alcohol, single food items, and soda limits are incorrect or unnecessary.
Which statement best describes the role of the medical-surgical nurse during a disaster?
- A. The nurse may be assigned to ride in the ambulance.
- B. The nurse may be assigned as a first assistant in the operating room.
- C. The nurse may be assigned to crowd control.
- D. The nurse may be assigned to the emergency department.
Correct Answer: D
Rationale: Medical-surgical nurses are often reassigned to the ED during disasters to manage increased patient loads. Ambulance, OR, and crowd control roles are less typical.
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.