A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?

Instruct a staff member to maintain a log of emergency care provided.

Apply cervical spine collars to children who have suspected neck trauma.

Notify guardians of the emergency and injuries to their children.

Survey the scene for potential hazards to staff and children.

Answer and Explanation

The Correct Answer is D

A. Instructing a staff member to maintain a log of emergency care provided is not the first action that the nurse should take. This is an important task, but it can be done later, after ensuring the safety of the staff and children and providing immediate care to those who need it.

B. Applying cervical spine collars to children who have suspected neck trauma is not the first action that the nurse should take. This is a priority intervention, but it can only be done after surveying the scene for potential hazards and making sure that it is safe to approach and touch the children.

C. Notifying guardians of the emergency and injuries to their children is not the first action that the nurse should take. This is a necessary step, but it can be delegated to another staff member or done after providing initial care to the children.

D. Surveying the scene for potential hazards to staff and children is the correct answer. This is the first action that the nurse should take, according to the principles of emergency care. The nurse needs to assess the situation and ensure that there are no dangers such as fire, electricity, gas, or falling debris that could harm anyone at the scene. The nurse also needs to determine how many children are injured, how severe their injuries are, and what resources are available to help them.

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Correct Answer is D

Explanation

- A. Instructing the client about the importance of regular medical appointments is important, but not the priority. The nurse should first ensure that the client knows how to manage their blood glucose levels and administer insulin at home.

- B. Encouraging the client to participate in daily exercise is beneficial, but not the priority. The nurse should first ensure that the client knows how to monitor their blood glucose levels and adjust their insulin dose accordingly.

- C. Explaining proper foot care techniques to the client is essential, but not the priority. The nurse should first ensure that the client knows how to prevent and treat hypoglycemia and hyperglycemia, which can have serious complications.

- D. Ensuring that the client understands the medication regimen is the priority. The nurse should teach the client about the types, actions, doses, and administration times of insulin, as well as how to store and dispose of it safely.

A. Irritability. B. Hypotonicity. C. Decreased auditory startle response. D. Increased head circumference.

Correct Answer is A

Explanation

Choice A rationale:

Irritability is a common withdrawal symptom in newborns exposed to cocaine during pregnancy. Cocaine exposure can lead to irritability, restlessness, and difficulty in consoling the newborn.

Choice B rationale:

Hypotonicity, or decreased muscle tone, is not a common finding associated with cocaine exposure in newborns. Cocaine exposure more commonly results in hypertonicity, where the muscles are tense and rigid.

Choice C rationale:

Decreased auditory startle response is not a typical finding associated with cocaine exposure. Newborns exposed to cocaine may have an exaggerated startle response, which is the opposite of the expected finding in this case.

Choice D rationale:

Increased head circumference is not a characteristic finding associated with cocaine exposure. Cocaine exposure is more likely to cause growth restriction, low birth weight, and microcephaly (small head size) in newborns.

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A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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