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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 nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death?
- A. The 84-year-old client exhibiting uncontrolled atrial fibrillation.
- B. The 60-year-old client exhibiting asymptomatic sinus bradycardia.
- C. The 53-year-old client exhibiting ventricular fibrillation.
- D. The 65-year-old client exhibiting supraventricular tachycardia.
Correct Answer: C
Rationale: Ventricular fibrillation is a lethal arrhythmia causing sudden cardiac death if untreated. Atrial fibrillation, bradycardia, and SVT are less immediately fatal.
The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator ensure is performed for legal purposes and continuity of care of the client?
- A. A person is ventilating with an Ambu bag.
- B. A person is performing chest compressions correctly.
- C. A person is administering medications as ordered.
- D. A person is keeping an accurate record of the code.
Correct Answer: D
Rationale: Accurate code documentation is critical for legal accountability and continuity of care. Ventilation, compressions, and medications are clinical priorities but less legally binding.
The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock?
- A. Monitor the client’s telemetry.
- B. Turn the client every two (2) hours.
- C. Administer oxygen via nasal cannula.
- D. Place the client in the Trendelenburg position.
Correct Answer: C
Rationale: Oxygen administration improves myocardial oxygenation, preventing cardiogenic shock post-MI. Telemetry monitors, turning prevents ulcers, and Trendelenburg is contraindicated.
The client has been brought to the ED by ambulance following a motor-vehicle accident with a flail chest, an intravenous line, and a Heimlich valve. Which intervention should the nurse implement first?
- A. Start a large-bore intravenous access.
- B. Request a portable chest x-ray.
- C. Prepare to insert chest tubes.
- D. Assess the cardiac rhythm on the monitor.
Correct Answer: C
Rationale: A flail chest with a Heimlich valve indicates a pneumothorax; preparing for chest tube insertion stabilizes breathing, the priority. Additional IVs, x-rays, and cardiac monitoring follow.
Which signs/symptoms should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin?
- A. A scabby, clear fluid-filled vesicle.
- B. Edema, pruritus, and a 2-mm ulcerated vesicle.
- C. Irregular brownish-pink spots around the hairline.
- D. Tiny purple spots flush with the surface of the skin.
Correct Answer: B
Rationale: Cutaneous anthrax presents with edema, pruritus, and a small ulcerated vesicle that becomes necrotic. Scabby vesicles, brownish-pink spots, and purple spots are not typical.