A nurse is caring for a client who was injured by a blast of high-order explosives. Medics report secondary injuries from the explosion. The nurse anticipates what type of injuries?

Blunt force trauma

Hollow organ damage

Post-trauma stress disorder

Penetrating injuries

Answer and Explanation

The Correct Answer is D

Choice A reason:

Blunt force trauma refers to injuries caused by impact with a blunt object, resulting in contusions, abrasions, lacerations, or fractures. While blunt force trauma can occur in explosions, it is typically associated with tertiary blast injuries, where the victim is thrown against a solid object. Secondary injuries from high-order explosives are more specifically related to penetrating injuries caused by flying debris and shrapnel.

Choice B reason:

Hollow organ damage is a type of primary blast injury caused by the overpressure wave from an explosion. This wave can cause significant damage to gas-filled organs such as the lungs, intestines, and ears. However, secondary injuries are not typically characterized by hollow organ damage. Secondary injuries are more commonly associated with penetrating trauma from debris and shrapnel.

Choice C reason:

Post-trauma stress disorder (PTSD) is a psychological condition that can develop after experiencing or witnessing a traumatic event. While PTSD is a serious and common consequence of exposure to explosions and other traumatic events, it is not classified as a secondary injury. Secondary injuries refer to physical injuries caused by flying debris and shrapnel, not psychological conditions.

Choice D reason:

Penetrating injuries are the hallmark of secondary blast injuries. These injuries occur when fragments from the explosive device or surrounding materials are propelled at high velocity, causing wounds that penetrate the skin and underlying tissues. These injuries can be severe and life-threatening, requiring immediate medical attention. The nurse should anticipate and be prepared to manage penetrating injuries in clients exposed to high-order explosives.

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Correct Answer is ["B","C","E"]

Explanation

Choice A reason:

Assigning the client to a private room is not the priority action in this scenario. The focus should be on decontamination and preventing the spread of the unknown substance to others in the emergency department. Isolation measures can be considered after initial decontamination.

Choice B reason:

Removing the client and transport crew from the Emergency department is a priority action to prevent contamination of the area and exposure to other patients and staff. This step helps contain the potential hazard and ensures the safety of everyone in the department.

Choice C reason:

Contacting the decontamination team is essential for managing the situation. The decontamination team has the expertise and equipment to safely remove the unknown substance from the client and transport crew, reducing the risk of further exposure and contamination.

Choice D reason:

Calling the scene to identify the chemical can be helpful, but it is not the immediate priority. The focus should be on decontamination and ensuring the safety of the client and others. Identifying the chemical can be done concurrently or after initial decontamination efforts.

Choice E reason:

Immediately removing the saturated clothing from the client is a critical step in the decontamination process. Removing contaminated clothing helps reduce the client’s exposure to the substance and prevents further absorption through the skin.

A. Assisting the client with active range of motion exercises. B. Maintaining strict bed rest to minimize cerebral blood flow. C. Monitoring vital signs and neurological status frequently. D. Administering anticoagulant medications as prescribed.

Correct Answer is C

Explanation

Choice A reason:

Assisting the client with active range of motion exercises is important for preventing complications such as contractures and maintaining mobility. However, it is not the priority intervention in the acute phase of a hemorrhagic stroke. The primary focus should be on stabilizing the client and monitoring their condition closely.

Choice B reason:

Maintaining strict bed rest to minimize cerebral blood flow is not appropriate for managing a hemorrhagic stroke. While bed rest may be necessary to prevent further injury, the priority is to monitor the client’s neurological status and vital signs to detect any changes that may indicate worsening of the condition.

Choice C reason:

Monitoring vital signs and neurological status frequently is the priority intervention for a client who has experienced a hemorrhagic stroke. Close monitoring allows the nurse to detect any changes in the client’s condition promptly and take appropriate action. This is crucial for preventing complications and ensuring timely intervention if the client’s condition deteriorates.

Choice D reason:

Administering anticoagulant medications is contraindicated in hemorrhagic stroke because they can exacerbate bleeding. Anticoagulants are used in ischemic stroke to prevent clot formation, but in hemorrhagic stroke, the focus is on controlling bleeding and stabilizing the client.

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A nurse is caring for a client who was injured by a blast of high-order explosives. Medics report secondary injuries from the explosion. The nurse anticipates what type of injuries?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting triage of clients transported from a mass casualty incident (MCI). A client arrives saturated with an unknown substance and medical transport reports feeling dizzy. The nurse should prioritize which actions? SELECT ALL THAT APPLY

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client who has experienced a hemorrhagic stroke. Which intervention should the nurse prioritize when providing care to the client?

Correct Answer is C

Explanation

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