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Questions and Answers
What color tag should be assigned to a patient with a penetrating head wound, burns over 60% of the body, and agonal respirations?
What color tag should be assigned to a patient with a penetrating head wound, burns over 60% of the body, and agonal respirations?
Which sign or symptom is associated with Blast Lung?
Which sign or symptom is associated with Blast Lung?
What condition is characterized by tympanic membrane rupture and is the most frequent injury from a pressure wave?
What condition is characterized by tympanic membrane rupture and is the most frequent injury from a pressure wave?
What action should a nurse take regarding a patient with an open abdominal injury and confusion?
What action should a nurse take regarding a patient with an open abdominal injury and confusion?
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Which patient assessment should the ER triage nurse prioritize in a multiple car crash scenario?
Which patient assessment should the ER triage nurse prioritize in a multiple car crash scenario?
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What is the primary diagnosis for a patient with a human bite and an unknown last tetanus shot?
What is the primary diagnosis for a patient with a human bite and an unknown last tetanus shot?
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Which disease has an incubation period of 12 days?
Which disease has an incubation period of 12 days?
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Which tag is assigned to stable abdominal wounds with no airway compromise?
Which tag is assigned to stable abdominal wounds with no airway compromise?
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What nursing diagnosis applies to a patient with difficulty maintaining an airway due to hemorrhage in the oral cavity?
What nursing diagnosis applies to a patient with difficulty maintaining an airway due to hemorrhage in the oral cavity?
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Which of the following symptoms is NOT associated with nerve gas exposure?
Which of the following symptoms is NOT associated with nerve gas exposure?
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What is the initial step that medical personnel should take at the scene of a disaster?
What is the initial step that medical personnel should take at the scene of a disaster?
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When decontamination begins, which action should be prioritized?
When decontamination begins, which action should be prioritized?
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Which medication is appropriate for treating a heroin overdose?
Which medication is appropriate for treating a heroin overdose?
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Which assessment finding in a patient who has taken an excessive amount of ASA indicates toxicity?
Which assessment finding in a patient who has taken an excessive amount of ASA indicates toxicity?
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What is the priority intervention for a patient presenting with hyperthermia and a temperature of 105°F?
What is the priority intervention for a patient presenting with hyperthermia and a temperature of 105°F?
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Which of the following conditions would be classified as 'green' in a disaster triage scenario?
Which of the following conditions would be classified as 'green' in a disaster triage scenario?
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Which interventions should be prioritized for a patient who has ingested poison?
Which interventions should be prioritized for a patient who has ingested poison?
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What clinical manifestations might indicate carbon monoxide poisoning?
What clinical manifestations might indicate carbon monoxide poisoning?
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When treating a snake bite, what is the first priority action?
When treating a snake bite, what is the first priority action?
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What is an essential nursing management practice for hemorrhage patients?
What is an essential nursing management practice for hemorrhage patients?
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When assessing a patient for heat stroke, which symptoms indicate a worsening condition?
When assessing a patient for heat stroke, which symptoms indicate a worsening condition?
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What is the priority intervention for a patient who has ingested poison?
What is the priority intervention for a patient who has ingested poison?
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Which medication can be used as a reversal agent for sedatives such as diazepam and lorazepam?
Which medication can be used as a reversal agent for sedatives such as diazepam and lorazepam?
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What should NOT be used in the initial management of snake bites within the first 6-8 hours?
What should NOT be used in the initial management of snake bites within the first 6-8 hours?
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Which clinical manifestation is commonly associated with carbon monoxide poisoning?
Which clinical manifestation is commonly associated with carbon monoxide poisoning?
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Which assessment finding is characteristic of a patient experiencing hemorrhage?
Which assessment finding is characteristic of a patient experiencing hemorrhage?
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Which symptoms are commonly associated with a person experiencing dyspnea following a blast injury?
Which symptoms are commonly associated with a person experiencing dyspnea following a blast injury?
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What is the possible consequence of a sucking chest wound in a patient?
What is the possible consequence of a sucking chest wound in a patient?
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Which tag classification should be assigned to a patient with upper extremity fractures and minor burns?
Which tag classification should be assigned to a patient with upper extremity fractures and minor burns?
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When dealing with a pandemic situation, healthcare providers are most concerned about reporting what to the CDC?
When dealing with a pandemic situation, healthcare providers are most concerned about reporting what to the CDC?
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Which of the following is a hallmark sign of anthrax during a clinical assessment?
Which of the following is a hallmark sign of anthrax during a clinical assessment?
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What is the primary nursing consideration for a patient with an open abdominal wound experiencing confusion?
What is the primary nursing consideration for a patient with an open abdominal wound experiencing confusion?
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What should be the focus of management for a patient who has sustained a blast injury resulting in tympanic membrane rupture?
What should be the focus of management for a patient who has sustained a blast injury resulting in tympanic membrane rupture?
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What is the expected response by a nurse to a patient post-disaster who desires to resume normal activities?
What is the expected response by a nurse to a patient post-disaster who desires to resume normal activities?
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Which symptom is considered a clinical manifestation of internal bleeding?
Which symptom is considered a clinical manifestation of internal bleeding?
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What is the first action a nurse should take when decontamination begins?
What is the first action a nurse should take when decontamination begins?
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Which condition requires a vaccine after exposure as a precaution in bioterrorism management?
Which condition requires a vaccine after exposure as a precaution in bioterrorism management?
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What is the priority intervention for a patient presenting with frostbite of the lower extremities?
What is the priority intervention for a patient presenting with frostbite of the lower extremities?
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In a disaster triage scenario, which condition would be classified as a 'green' or minor priority?
In a disaster triage scenario, which condition would be classified as a 'green' or minor priority?
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What should a nurse do first when there is a chemical spill on workers?
What should a nurse do first when there is a chemical spill on workers?
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Which medication should be administered to a patient experiencing a heroin overdose?
Which medication should be administered to a patient experiencing a heroin overdose?
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Which symptom is NOT associated with nerve gas exposure?
Which symptom is NOT associated with nerve gas exposure?
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Study Notes
Disaster Triage
- Black Tag: Penetrating head wound, burns over 60% of the body, agonal respirations, no blood pressure, fixed and dilated pupils
- Red Tag: Sucking chest wound, shock, hemothorax, asphyxia, incomplete amputations, open fractures
- Yellow Tag: Stable abdominal wounds, soft tissue injuries, maxillofacial wounds without airway compromise
- Green Tag: Upper extremity fractures, minor burns, sprains, behavioral disorders
- Involved/White Tag: No apparent injuries but involved in the situation
Disaster Nursing
- Blast Lung: Dyspnea, hypoxia, tachypnea, apnea, cough, chest pain, hemodynamic instability
- Tympanic Membrane Rupture: Most frequent injury from a pressure wave with symptoms of hearing loss, tinnitus, pain, dizziness, and otorrhea
- Head Injury: Most common cause of post-blast deaths, usually caused by falling debris or the blast itself
- Anthrax: Hallmark sign of anthrax is mediastinum hemorrhaging, incubation period varies
- Smallpox: Incubation period is 12 days
- Acute Radiation Syndrome: Probable survivors have no initial symptoms or minimal symptoms (nausea and vomiting)
- CISM Components: Education, Field support, Defusing, Debriefing, Demobilization, Follow-up
- Open Abdominal Injury: Priority is to stop bleeding and start normal saline solution, do not force oral fluids
- Priority Assessment in ER: Deviated trachea, unequal pupils, ecchymosis in flank area, tachycardia
- Human Bite: Priority diagnosis is risk for infection related to organisms in human bite
- Hemorrhage in Oral Cavity: Nursing diagnosis is ineffective airway clearance
- Disaster Scene Initial Step: Triaging
- Nerve Gas Exposure: Symptoms include visual disturbances, flaccid muscles, nausea and vomiting, not constipation
- Decontamination Priority: Double bag all waste, collect all water used in decontamination, cover the floor
- Improbable Radiation Survivor: Bloody diarrhea
- Cutaneous Anthrax Treatment: Cleanse skin with soap and water
- Botulism Treatment: Mechanical ventilation
- Chemical Spill on Workers: Continuously flush the skin with water
- Heroin Overdose Medication: Naloxone
- Emergency Triage in ER: Stridor and oxygen level of 75%
- Priority Assessment in ER: Patient with multiple injuries from an MVA
- CISM Defusing Component: Learning to identify stress reactions and how to manage them
- "Green" Tag in Disaster Triage: Broken thumb from falling debris
- Bioterrorism Agent requiring vaccine after exposure: Smallpox
- ASA Overdose Clinical Manifestation: Tinnitus
- External Hemorrhage Priority Intervention: Stop the bleeding
- Hyperthermia Priority Intervention: Place a cooling blanket on the patient
- Frostbite Intervention: Soak feet in warm water for 30-40 minutes at a time
- Internal Bleeding Clinical Manifestation: Increased pulse rate
- Frostbite Avoidance: Avoid ETOH and caffeine
- Poison Ingestion Priority Intervention: Remove or inactivate poison ASAP
- Carbon Monoxide Poisoning Clinical Manifestations: Skin color ranges from pink to red, confused, headache, decreased LOC, muscular weakness, palpitation, dizziness
- Snake Bite Priority Intervention: Remove restrictive items
- Nurse's Role in Disaster: Do the greatest good for the person you can save, not save everyone
- Sedative Reversal Agent: Flumazenil
- Lye and White Phosphorus: Do not wear gloves when rinsing off
- Snake Bite Treatment: Antivenom most effective within 4 hours of bite, measure arm to monitor swelling, take a picture to document, DO NOT USE: ice, tourniquets, heparin, or steroids in the first 6-8 hours.
Hemorrhage
- Nursing Management: Two large-bore IVs (18 gauge preferred, 20 gauge okay), type and cross-match blood, IV fluids (NS or Lactated Ringers), platelets to help clot
- Clinical Manifestations: Clammy skin, decreased blood pressure, rigid abdomen
- Heat Stroke Progression: Confusion, delirium, elevated body temperature with hot dry skin, no sweating, decreased blood pressure, increased respiratory rate, and heart rate
Disaster Triage Tags
- Black Tag: Penetrating head wound, over 60% body burns, agonal respirations, no blood pressure, fixed and dilated pupils.
- Red Tag: Sucking chest wound, shock, hemothorax, asphyxia, incomplete amputations, open fractures.
- Yellow Tag: Stable abdominal wounds, soft tissue injuries, maxillofacial wounds without airway compromise.
- Green Tag: Upper extremity fractures, minor burns, sprains, behavioral disorders.
- Involved/White Tag: Individuals involved in an event but have no apparent injuries.
Disaster Health Care
- CDC Reporting: Health care providers should report an increase in certain diseases in a normally healthy population.
Blast Lung
- Signs and Symptoms: Dyspnea, hypoxia, tachypnea, apnea, cough, chest pain, hemodynamic instability.
Tympanic Membrane Rupture
- Most frequent injury from a pressure wave.
- Signs and Symptoms: Hearing loss, tinnitus, pain, dizziness, otorrhea.
Head Injury
- Most common cause of post-blast deaths, usually caused by falling debris or the blast itself.
Anthrax
- Hallmark Sign: Mediastinum hemorrhage.
Smallpox
- Incubation period is 12 days.
Acute Radiation Syndrome
- Probable Survivors: No initial symptoms or only minimal symptoms (nausea, vomiting).
Post-Disaster Patient Care
- Encourage patients to return to normal activities.
Critical Incident Stress Management (CISM)
- Components: Education, Field support, Defusing, Debriefing, Demobilization, Follow-up.
Open Abdominal Injury ER Nursing
- Questionable Order: Force oral fluids.
ER Triage Priorities
- Highest Priority: Deviated trachea.
- Other Priorities: Unequal pupils, ecchymosis in the flank area, tachycardia.
ER Nursing - Open Abdominal Wounds
- Priority: Stop the bleeding and start normal saline.
Human Bite Wound
- Priority Diagnosis: Risk for infection related to organisms in human bites.
Oral Cavity Hemorrhage
- Nursing Diagnosis: Ineffective airway clearance.
Bioterrorism Agents
- Botulism and anthrax can be disseminated.
Disaster Scene Medical Personnel
- Initial Step: Triaging.
Nerve Gas Exposure
- Symptoms: Visual disturbances, flaccid muscles, nausea and vomiting.
- Not a symptom: Constipation.
Decontamination
- Priority Actions: Double bag all waste, collect all water used in decontamination, cover the floor.
- Not a priority: Open air duct.
Radiation Exposure
- Improbable Survivor Symptom: Bloody diarrhea.
Cutaneous Anthrax Treatment
- Cleanse skin with soap and water.
Botulism Treatment
- Mechanical ventilation.
Chemical Spill on Workers
- First Action: Continually flush the skin with water.
Heroin Overdose Medication
- Naloxone.
ER Triage Emergency Criteria
- Emergency: Stridor, O2 saturation of 75%.
ER Triage Priority Assessment
- Highest Priority: Patient with multiple injuries from a motor vehicle accident (MVA).
Critical Incident Stress Management: Defusing
- Involves learning to identify stress reactions and how to manage them.
Disaster Triage "Green" Tag Criteria
- Broken thumb from falling debris.
Smallpox Treatment
- Requires a vaccine after exposure.
Excessive Aspirin Ingestion
- Clinical Manifestation: Tinnitus.
External Hemorrhage Priority Intervention
- Stop the bleeding.
Hyperthermia Intervention
- Place a cooling blanket on the patient.
Lower Extremity Frostbite
- Soak feet in warm water for 30-40 minutes at a time.
Internal Bleeding
- Clinical Manifestation: Increased pulse rate.
Frostbite - Avoid
- ETOH and caffeine.
Poison Ingestion
- Priority Intervention: Remove or inactivate the poison as soon as possible.
Carbon Monoxide Poisoning
- Clinical Manifestations: Skin color ranging from pink to red, confusion, headache, decreased level of consciousness, muscular weakness, palpitations, dizziness.
Snake Bite
- Priority: Remove restrictive items.
Nurse's Role in Disaster Management
- The nurse's role is NOT to do the greatest good for the person you can save. The role incorporates all individuals during a disaster.
Sedative Reversal Agent
- Flumazenil.
Lye and White Phosphorus
- Do not wear gloves when rinsing off.
Snake Bite Treatment
- Most Effective: Antivenom within 4 hours of the bite.
- Measure arm: Monitor swelling. Take a picture to document.
- Do NOT use: Ice, tourniquets, heparin, or steroids in the first 6-8 hours.
Hemorrhage Nursing Management
- Ensure two large-bore IVs: (18 gauge preferred, 20 gauge acceptable). Needed to administer blood.
- Type and cross-match blood: For transfusion.
- IV Fluids: Normal saline (NS) or Lactated Ringers.
- Platelets: May be administered to help clot.
Hemorrhage Clinical Manifestations
- Clammy skin, decreased blood pressure.
- Rigid abdomen.
Heat Stroke Progression
- Signs and Symptoms: Confusion, delirium, elevated body temperature with hot dry skin, no sweating, decreased blood pressure, increased respiratory rate, increased heart rate.
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Description
This quiz covers critical concepts in disaster triage and nursing care for various injuries and conditions. Participants will learn how to classify injuries using the triage tagging system and identify key injuries commonly seen in disaster situations. Perfect for nursing students and emergency responders.
