A female adult who works in the mailroom of an ammunitions plant opened an envelope that contained a white powder. Believing that she might have been exposed to anthrax, the client is immediately transported to the emergency department (ED) of a local hospital. Which intervention(s) in the emergency disaster response plan should the nurse implement? Select all that apply.
Instruct the client to shower and wash her hair thoroughly.
Clean all surfaces touched by the client with vinegar and water.
Place the client in a room with lead doors to contain airborne anthrax.
Bag the clothes the client is wearing in plastic bags.
Place the client on airborne precautions.
Correct Answer : A,D,E
Rationale:
A. Instruct the client to shower and wash her hair thoroughly: Decontamination by showering is essential to remove any anthrax spores from the skin and hair. Thorough washing reduces the risk of further spread and protects healthcare personnel and other patients.
B. Clean all surfaces touched by the client with vinegar and water: Vinegar and water are not effective against anthrax spores. Proper decontamination requires specific agents, such as a 0.5% hypochlorite (bleach) solution, under the guidance of hazardous materials protocols.
C. Place the client in a room with lead doors to contain airborne anthrax: Lead doors are used for radiation containment, not for biological threats like anthrax. Anthrax is not typically airborne unless aerosolized, so this intervention is unnecessary and ineffective.
D. Bag the clothes the client is wearing in plastic bags: Contaminated clothing can carry anthrax spores. Placing clothes in sealed plastic bags is a critical step in preventing environmental contamination and ensuring safe disposal.
E. Place the client on airborne precautions: While anthrax is not usually spread from person to person, airborne precautions are used if aerosol exposure is suspected, as in bioterrorism events. This helps contain spores until full decontamination is completed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. A salad with three kinds of lettuce and fruit: While this meal is rich in vitamins and fiber, it lacks a significant source of protein necessary for wound healing. Leafy greens and fruits contribute micronutrients but provide minimal protein content.
B. A peanut butter sandwich with soda and cookies: Peanut butter contains some protein, but the overall meal is high in sugar and low in high-quality protein. The presence of soda and cookies further reduces the nutritional adequacy for promoting wound healing.
C. Vegetable soup, crackers, and milk: Milk does provide some protein, but the rest of the meal is low in protein-dense items. Vegetable soup and crackers are mostly carbohydrates and contribute very little to the client’s protein requirements.
D. A tuna fish sandwich with chips and ice cream: Tuna is a high-quality source of complete protein, which is essential for tissue repair. Though chips and ice cream are not ideal nutritionally, the inclusion of tuna makes this the most protein-rich option to support wound healing.
Correct Answer is A
Explanation
Rationale:
A. Ask the client to describe the pain: Describing the pain in the client's own words helps determine the pain’s quality, such as whether it's throbbing, stabbing, or dull. This subjective data is critical for diagnosing migraine type. It provides insight into patterns and guides individualized treatment options.
B. Provide a numeric pain scale: The numeric pain scale measures intensity, not quality, of pain. While important, it does not offer specific details on the sensation or nature of the migraine. It is more effective for tracking changes in pain severity over time.
C. Identify effective pain relief measures: This evaluates which interventions are working, not the type of pain being experienced. It is valuable for long-term management but doesn't assist with assessing the sensory qualities of current pain..
D. Observe body language and movement: Observation gives indirect clues about pain presence but not quality. Body language may suggest discomfort, yet it cannot replace verbal descriptions of the pain's nature.
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