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The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation?
- A. Contaminated water is the only source of transmission of biological agents.
- B. Vaccines are available and being prepared to counteract biological agents.
- C. Biological weapons are less of a threat than chemical agents.
- D. Biological weapons are easily obtained and result in significant mortality.
Correct Answer: D
Rationale: Biological weapons are easily obtained (e.g., anthrax) and cause high mortality, making them a significant threat. Water is not the only transmission route, vaccines are limited, and biological threats rival chemical ones.
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The client presents to the ED with acute vomiting after eating at a fast-food restaurant. There has not been any diarrhea. The nurse suspects botulism poisoning. Which nursing problem is the highest priority for this client?
- A. Fluid volume loss.
- B. Risk for respiratory paralysis.
- C. Abdominal pain.
- D. Anxiety.
Correct Answer: B
Rationale: Botulism causes progressive paralysis, including respiratory muscles, making respiratory paralysis the highest priority. Fluid loss, pain, and anxiety are secondary.
The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing?
- A. The hypodynamic phase.
- B. The compensatory phase.
- C. The hyperdynamic phase.
- D. The progressive phase.
Correct Answer: A
Rationale: The hypodynamic (cold) phase of septic shock involves hypotension, low urine output, and cool, pale skin due to vasoconstriction. Compensatory is early, hyperdynamic is warm, and progressive involves organ failure.
The client who was abused as a child is diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement when the client is resting?
- A. Call the client’s name to awaken him or her, but don’t touch the client.
- B. Touch the client gently to let him or her know you are in the room.
- C. Enter the room as quietly as possible to not disturb the client.
- D. Do not allow the client to be awakened at all when sleeping.
Correct Answer: A
Rationale: Calling the name without touching avoids startling a PTSD client, preventing flashbacks. Touching, quiet entry, or preventing awakening may trigger or disrupt.
The ED nurse is working triage. Which client should be triaged first?
- A. A client who has multiple injuries from a motor-vehicle accident.
- B. A client complaining of epigastric pain and nausea after eating.
- C. An elderly client who fell and fractured the left femoral neck.
- D. The client suffering from a migraine headache and nausea.
Correct Answer: A
Rationale: Multiple trauma from an MVA suggests life-threatening injuries, requiring immediate triage. Epigastric pain, fractures, and migraines are less urgent.
The nurse is responding to a disaster call from home following a multivehicle motor-vehicle accident. Which action should the nurse take first?
- A. Go to the emergency department to triage the clients coming in.
- B. Assist the charge nurse to identify clients who could be discharged.
- C. Report to the command center for assignment.
- D. Pack a bag to be able to stay until the emergency is over.
Correct Answer: C
Rationale: Reporting to the command center ensures coordinated assignment per disaster protocol. Triaging, discharging, or packing are secondary.