A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community.
Which of the following actions should the nurse plan to take
Call in additional medical-surgical unit nursing care staff
Act as a liaison between the facility and the media
Determine the medical needs of incoming clients through the emergency department.
Recommend to the provider specific acute care clients for discharge.
None
None
The Correct Answer is D
Choice A rationale: Calling in additional staff is typically a function of the nursing supervisor or the hospital’s incident command center, rather than the responsibility of a single medical-surgical unit nurse.
Choice B rationale: Acting as a media liaison is the role of the Public Information Officer. Nurses must maintain patient confidentiality and follow the established chain of command during a mass casualty event.
Choice C rationale: Determining the needs of incoming clients (triage) is performed by emergency department staff or designated triage officers at the scene, not by nurses working on a medical-surgical inpatient unit.
Choice D rationale: To create bed capacity for incoming disaster victims, the medical-surgical nurse identifies stable clients who can safely be discharged or transferred, recommending these specific individuals to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice d. Positioning both hands on the grips with his elbows slightly flexed.
Choice A rationale:
- Moving both crutches with the stronger leg forward first is incorrect for a three-point gait.This describes a two-point gait,which is used when a client can bear weight on both legs.In a three-point gait,the client bears weight on the unaffected leg and the crutches,not the stronger leg.
- This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.
Choice B rationale:
- Supporting his body weight while leaning on the axillary crutch pads is also incorrect.This can lead to nerve damage in the armpits and should be avoided.
- The weight should be distributed through the hands and wrists,not the armpits.
Choice C rationale:
- Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous.The client should lead with the stronger leg when going up stairs to maintain balance and control.
Choice D rationale:
- Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait.This allows for proper weight distribution,balance,and control of the crutches.
- It also helps to prevent fatigue and strain in the arms and shoulders.
Key points to remember about the three-point gait:
- Weight is borne on the unaffected leg and the crutches,not the affected leg.
- The crutches and the unaffected leg move forward together,followed by the affected leg.
- The client should look ahead,not down at their feet.
- The client should take small,even steps.
- The client should rest as needed.
Correct Answer is A
Explanation
The correct answer is choice A. “I can give you information about respite care if you are interested.” Respite care is a service that provides short-term inpatient care for terminally-ill patients at a professional care facility, such as a hospital, hospice inpatient care facility, or nursing home. It is meant to relieve caregiver stress and offer them rest and time away from caregiving duties. Respite care is covered by Medicare for up to five consecutive days and no more than one respite period in a single billing period.
The nurse should offer this option to the son who is experiencing sleep deprivation due to caring for his mother.
Choice B is wrong because it suggests that the son should rely on medication to cope with his situation, which may not be appropriate or effective.
Sleeping pills may have side effects or interactions with other drugs, and they do not address the underlying cause of the son’s stress and fatigue.
Choice C is wrong because it does not acknowledge the son’s need for support or assistance.
It may sound like an empty compliment or a dismissal of the son’s concerns.
The nurse should express empathy and compassion, but also provide information and resources that can help the son.
Choice D is wrong because it does not offer any solution or guidance to the son.
It may also sound like a cliché or a generalization that does not reflect the son’s unique experience.
The nurse should avoid making assumptions or judgments about the son’s feelings or situation, and instead focus on his needs and preferences.
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