A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community.
Which of the following assignments should the nurse anticipate?
Assist in discharging stable clients to home.
Determine the acuity and number of casualties arriving at the facility.
Delegate tasks to emergency health care specialists.
Provide informational updates to members of the media.
The Correct Answer is B
Choice A rationale:
Assisting in discharging stable clients to home is not the most appropriate assignment when a mass casualty event has occurred. During such events, resources are needed for critically injured patients, and stable clients can typically be discharged by non-emergency staff.
Choice B rationale:
Determining the acuity and number of casualties arriving at the facility is the most appropriate assignment during a mass casualty event. This information is critical for allocating resources and providing the necessary level of care to those affected.
Choice C rationale:
Delegating tasks to emergency healthcare specialists may be necessary, but it is not the initial assignment for the nurse working on a medical-surgical unit. Assessing the situation and determining the acuity of incoming casualties take precedence.
Choice D rationale:
Providing informational updates to members of the media is not the role of a nurse during a mass casualty event. This task should be handled by hospital public relations or designated spokespersons to ensure accurate and controlled information dissemination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,B,C,A
Explanation
Rationalizing the Priority
1. Airway/Breathing (D):
The "A" and "B" of the ABCs take precedence. In myxedema coma, hypoventilation is a primary concern. The client may experience respiratory muscle weakness or a decreased drive to breathe, leading to CO₂ retention and respiratory failure. Assessing the rate, depth, and effort of breathing is the absolute first step.
2. Circulation (B):
Once the airway is confirmed, you assess the "C" (Circulation). Myxedema coma causes severe bradycardia and decreased cardiac output, which leads to hypotension. Assessing blood pressure tells the nurse if the client is in cardiogenic shock.
3. Vital Signs/Metabolic State (C):
Hypothermia is a hallmark sign of myxedema coma (temperatures can often drop below 95°F or 35°C). While critical, it is addressed after ensuring the heart is pumping and the lungs are moving air. Monitoring temperature is vital because rapid rewarming can actually cause vasodilation and worsen shock.
4. Focused Physical Assessment (A):
Palpating for edema is an important part of a head-to-toe assessment for hypothyroidism (non-pitting mucinous edema is common), but it is not a life-saving intervention. It is a secondary assessment compared to the vital signs and respiratory status.
Correct Answer is C
Explanation
Choice A rationale:
Ketonuria is not a common complication of diabetes insipidus. Ketonuria is associated with diabetes mellitus, a different condition that results in the accumulation of ketones in the urine due to insufficient insulin.
Choice B rationale:
Peripheral edema is also an unlikely complication of diabetes insipidus. Diabetes insipidus is characterized by excessive thirst and urination, not fluid retention or peripheral edema.
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