A. Food contamination from flood waters can lead to gastrointestinal issues, but in disaster scenarios, contaminated drinking water is a more common source of widespread diarrhea.

B. Close living quarters at evacuation centers can contribute to the spread of infectious diseases, but they are less likely to be the primary source of contamination compared to drinking water.

C. Nosocomial transmission in the medical area is possible but less likely to be the primary source of widespread diarrhea among disaster victims.

D. Drinking water contaminated by sewage is a common and significant source of gastrointestinal infections, especially in disaster scenarios where infrastructure may be compromised.

A. Auscultating bowel sounds in all quadrants helps assess the extent of gastrointestinal involvement and possible complications.

B. Administering warfarin is not appropriate in this acute situation where there may be active bleeding; instead, the heparin infusion should be stopped.

C. Assessing the characteristics of the pain is crucial for determining the severity and possible source of the gastrointestinal symptoms.

D. Monitoring stools for the presence of blood is essential to confirm gastrointestinal bleeding and the extent of blood loss.

E. Reviewing the last partial thromboplastin time results helps assess the anticoagulation status of the client and the potential need for reversal.

A. Shuffling gait and stooped posture are common side effects of antipsychotic medications and may require intervention but are not immediately dangerous.

B. Rocking back and forth in the chair can be a self-soothing behavior in individuals with schizophrenia and usually does not require immediate intervention.

C. Muscle spasms of the back and neck (dystonia) can be a sign of a serious side effect of antipsychotic medications known as extrapyramidal symptoms and require immediate intervention to prevent complications such as airway obstruction.

D. Lip smacking and frequent eye blinking can indicate tardive dyskinesia, a long-term side effect of antipsychotic medication, but it is not an immediate emergency.

A. In emergency situations where immediate surgery is required to save a client's life and no family members are available, healthcare providers can proceed without signed informed consent based on implied consent for life-saving treatment.

B. Seeking an emergency court order would delay necessary treatment and is not the priority in an immediate life-threatening situation.

C. A friend typically does not have the legal authority to sign informed consent unless legally designated as the client's healthcare proxy.

D. Continuing to provide life support without proceeding with necessary surgery could jeopardize the client's life.

A. Serum sodium level is not directly related to the presence of infection or the client's ability to fight infection.

B. Platelet count is important for assessing bleeding risk but is not directly related to infection.

C. Hematocrit levels are related to the client's blood volume and anemia status but do not directly indicate infection.

D. Neutrophil count is crucial for assessing the client’s immune response and ability to fight infection. An elevated neutrophil count could indicate an ongoing infection, while a low count could suggest an immunocompromised state.

A. Instituting droplet precautions, placing the client in a private room, and keeping the door closed are critical actions to prevent the spread of COVID-19 within the healthcare facility. These measures protect other clients and healthcare workers from potential exposure to the virus.

B. Notifying the charge nurse is important but should follow the immediate action of instituting droplet precautions to prevent transmission.

C. Updating the client and family about available COVID-19 vaccines is essential for future prevention but does not address the immediate need to prevent virus spread.

D. Teaching the client to wear a mask, hand wash, and social distance is important, but immediate isolation and droplet precautions take precedence to contain potential spread within the facility.

A. Falls can lead to head injuries or subdural hematomas, which can cause confusion in older adults. It is important to assess for recent trauma as a possible cause of the confusion.

B. An elevated temperature can indicate an infection, such as a urinary tract infection (UTI) or pneumonia, which are common causes of acute confusion in older adults.

C. Pain with urination is a symptom of a UTI, which can lead to confusion, especially in elderly patients with Parkinson's disease.

D. While maintaining adequate nutrition is important, increasing protein intake does not directly address the sudden onset of confusion.

E. New medications or allergic reactions can lead to confusion. A medication interaction or an allergic reaction to a new food could be a contributing factor.

A. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.

B. Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.

C. Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.

D. Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.

A. Osteoarthritis is primarily caused by the destruction of joint cartilage, which leads to pain, stiffness, and decreased mobility in the affected joints. This degenerative process is the hallmark of the condition.

B. Loss of bone mineral density is associated with osteoporosis, not osteoarthritis. While both conditions can cause joint pain, they have different underlying pathologies.

C. An infectious process in the synovial fluid would indicate septic arthritis, which is an acute and severe condition requiring different management.

D. A systemic inflammatory response is more characteristic of rheumatoid arthritis, an autoimmune condition, rather than osteoarthritis, which is a degenerative joint disease.

A. Listening for extra heart sounds, murmurs, and rhythm is important, but obtaining an ECG and starting continuous monitoring should be prioritized to assess for possible acute coronary syndrome.

B. Reducing environmental stimuli is beneficial for patient comfort but is not the immediate priority in assessing and managing potential cardiac events.

C. Obtaining a 12-lead electrocardiogram and beginning continuous cardiac monitoring are critical actions to diagnose and monitor for myocardial infarction or other cardiac events. These steps provide vital information for immediate treatment decisions.

D. Restricting family and visitors may be necessary but is not the immediate next action compared to performing an ECG and continuous monitoring to assess the client's cardiac status.