Emergency Response Scenarios

• In disaster triage, prioritize patients with difficulty breathing and cyanosis.
• The primary goal when responding to a bioterrorism attack is to identify the agent and contain its spread.
• A common complication of unintentional injury or trauma is increased intracranial pressure.
• A key finding in hypovolemic shock is hypotension and tachycardia.
• If a patient in septic shock has a blood pressure of 82/50 mmHg despite fluid resuscitation, the next priority action is to administer a vasopressor medication.
• Anaphylaxis is the likely cause when a patient in distributive shock presents with warm, flushed skin and a normal or elevated cardiac output
• High fever, chills, and hypotension indicate the presence of sepsis.
• For a patient with advanced burns receiving fluid resuscitation, closely monitor heart rate and blood pressure.
• When managing a traumatic brain injury (TBI), performing frequent neurological assessments is a priority.
• During triage following a disaster, a "red tag" means the patient has life-threatening injuries that require immediate care.
• The primary responsibility of a nurse during a bioterrorism event is identifying signs and symptoms of exposure to the biological agent.
• Motor vehicle accidents are most commonly associated with spinal cord injuries.
• For a patient with hypovolemic shock after a car accident, the nurse anticipates initiating fluid resuscitation with normal saline.
• The most appropriate treatment for septic shock with hypotension despite fluid resuscitation is antibiotic therapy and vasopressors.
• A patient with distributive shock is most likely caused by spinal cord injury.
• Expect a patient with sepsis to have an increased lactate level when tissue perfusion is impaired.
• A hallmark of advanced burns requiring urgent care is an increased heart rate and decreased blood pressure.
• The most important intervention for a patient with a TBI and signs of increased intracranial pressure is elevating the head of the bed to 30 degrees.
• In disaster triage, the "black tag" is for patients who are deceased or whose injuries are not survivable.
• An unusual cluster of cases in a geographic area indicates bioterrorism as a possible cause of illness.
• For a patient with hypovolemic shock showing rapid breathing and weak pulse, the nurse's first intervention should be to begin fluid resuscitation with intravenous fluids.
• A critical sign of septic shock with a history of infection is hypotension despite adequate fluid resuscitation.
• Warm and flushed skin is a characteristic finding in distributive shock, such as in septic shock.
• When a patient with sepsis has been started on antibiotics the most important nursing intervention is ensuring adequate oxygenation and ventilation.
• Severe blood loss is the primary cause of hypovolemic shock.
• For a patient with severe burns to 40% of their body, the priority action in the first 24 hours is to initiate fluid resuscitation based on the Parkland formula.
• For a patient with a traumatic brain injury showing signs of increased intracranial pressure, hyperventilating the patient to reduce CO2 levels would be most effective.
• Hypovolemic shock is the most common complication of burns covering more than 30% of the body.
• For a patient with distributive shock from anaphylaxis, the nurse should anticipate administering epinephrine.
• For a patient with a head injury at risk for increased intracranial pressure, maintaining the head of the bed at 30 degrees is appropriate.
• In a bioterrorism event involving anthrax exposure, providing antibiotics to those exposed is the priority action.
• Head trauma is most commonly associated with unintentional injury due to falls in elderly adults.
• Aggressive fluid resuscitation is the priority for improving perfusion when managing a patient with septic shock.
• Administering intravenous fluids to restore circulating volume is the most important intervention for a patient with severe hypovolemic shock following a car accident.
• Septic shock is caused by infection, while hypovolemic shock is caused by blood loss.
• For a patient in distributive shock following a severe allergic reaction, epinephrine would most likely be administered.
• Sudden fever and chills, followed by a drop in blood pressure, suggest the development of sepsis.
• For a patient with a TBI exhibiting signs of increased intracranial pressure, performing frequent neurological assessments and monitoring vital signs is the most appropriate nursing intervention.
• Fluid resuscitation is the first step of care in the management of advanced burns.
• Providing supportive care is the primary focus of nursing care in the event of a bioterrorism attack involving smallpox.
• The primary purpose of administering vasopressors to a patient with septic shock is to restore blood pressure and improve tissue perfusion.
• The nurse would expect to administer packed red blood cells to a patient with hypovolemic shock due to severe gastrointestinal bleeding.
• Elevated lactate levels would be the most concerning laboratory result for a patient with septic shock.
• The nurse should expect to administer blood products and crystalloids in the early stages of hypovolemic shock.
• Assessing the patient's fluid status and adjusting resuscitation as needed is the priority action for a patient with distributive shock from sepsis being treated with fluids and antibiotics.
• Hyperkalemia is the most likely complication to occur during the first 48 hours for a patient being monitored with advanced burns.
• Tachycardia and hypotension is a characteristic of hypovolemic shock in trauma patients.
• Elevating the head of the bed to 45 degrees should be the nurse's first priority for a patient with a TBI showing signs of increased intracranial pressure.
• In disaster triage, the most appropriate action for a patient who has a minor head injury and is conscious and alert is to assign a green tag.
• Administering intravenous fluids and antibiotics is a priority nursing intervention in the management of a patient with septic shock.
• Administer oxygen as ordered and monitor vital signs.

Spinal Cord

• If a patient with a spinal cord injury at the C6 level is experiencing a decrease in vital capacity and difficulty breathing administering oxygen as prescribed is the priority nursing intervention.

Epiglottitis

• Endotracheal intubation should be prepared if a patient with epiglottitis presents with difficulty swallowing and drooling.
• Call the Poison Control Center first, if the nurse is caring for a patient with suspected poisoning due to ingestion of a household chemical.
• Move the patient to a cool, shaded area and provide oral rehydration is the most appropriate initial intervention if a patient presents with hyperthermia after prolonged exposure to the sun.

Hypothermia

• The nurse should avoid applying external heat sources directly to the skin during the initial rewarming phase of a patient with hypothermia.

Brown Recluse Spider Bites

• After a Brown recluse spider bite administer pain medication and observe for signs of necrosis.

Snake Bites

• Immobilizing the affected extremity and keep it below the level of the heart should happen when a patient with a snake bite from a non-venomous species presents with local swelling.

Near Drowning

• For a child in the emergency room after near-drowning, monitor the child's neurological status and provide oxygen therapy.
• A patient with a spinal cord injury at the T12 level is at risk for paralysis of the lower extremities.
• The priority concern for is airway obstruction if a nurse is caring for a patient with epiglottitis.
• Cyanosis and decreased level of consciousness is most indicative of carbon monoxide poisoning of a patient.
• Move the patient to a cooler environment and administer intravenous fluids.
• The nurse's priority intervention if a patient with hyperthermia secondary to heat stroke.
• Apply warm blankets and monitor vital signs if a patient with hypothermia presents with shivering, confusion, and slurred speech.
• Administer pain medications to control discomfort if a patient with a snake bite from a copperhead presents with severe pain, swelling, and redness around the bite site.
• A patient with severe epiglottitis most common symptoms are drooling and difficulty swallowing in a child.
• Remove wet clothing and apply warm blankets if a nurse is caring for a patient who is in the early stages of hypothermia.
• A patient with spinal cord injury at the C3 level is at high risk for respiratory compromise and inability to breathe independently.
• Formation of a central ulcer with a surrounding ring of redness suggests the development of necrosis at the bite site.
• Ensure the patient is awake and alert enough to swallow is an important point, while administering activated charcoal for a patient's toxic digestion.
• Begin cooling the patient by immersion in ice water.
• Keep the child calm and avoid using a tongue depressor to examine the throat.
• A patient with hypothermia suspected will have slurred speech and confusion.
• Spasticity in the lower limbs is has risk for a patient with a spinal cord injury at the L2 level.
• The nurse should avoid attempting to visualize the throat with a tongue depressor.
• Systemic symptoms such as abdominal pain, muscle cramps, and dizziness can indicate a severe reaction for a black widow bite.
• Neurogenic shock affects a patient with a spinal cord injury at the T3 level presents and loss of temperature regulation.
• The nurse should keep the patient calm and immobilize the affected extremity with a snake bite.
• The nurse should first prepare for endotracheal intubation, for a child with suspected epiglottitis, drooling, and running a fever.
• Administer oxygen and monitor vital signs for a patient with Inhaling toxic fumes.
• Administer intravenous fluids to restore hydration for hyperthermia.
• A patient with hypothermic give shivering, confusion, and slurred speech, begin rewarming the patient gradually with warm blankets.
• Administer oxygen and monitor signs for honeybee sting.
• Ensure respiratory rate is normal for patients with C5 levels.
• The nurse should place the child in a sitting position and keep them calm and avoid tongue blades.
• The nurse should administer antivenom immediately for a patient with snakebite symptoms.
• You should Initiate cardiopulmonary resuscitation (CPR) if necessary to save a patient from near drowning.
• For a patient with hypothermia Begin warming the patient with hot packs applied to the chest.
• Autonomic dysreflexia due to irritation belove the level of injury.
• Stabilize vital signs and administer oxygen and fluid
• You should Administer 100% oxygen via non-rebreather mask
• You should Immerse the patient in cool water or ice packs
• You should Establish an airway and assist with breathing
• Bladder detention or bowel impactation is a main indicator.
• Fever should be given to children for this disease.
• Call poison control and listen for guidance.
• B. Monitor the 02 and give accordingly in the patient air way.
• They should be covered in room temp by nurses.
• Call poison control and await guidance.
• B. Respiratory failure due to lung disfunction.
• Call poison control and await instructions.