NURSING PRACTICE — Care of
Clients with Physiologic and
Psychosocial Alterations, Part B
Below is the complete Section 4 (Questions 1–100)
in correct exam format, with the question, answer
and a rationale for each.
1. The nurse prepares the department to receive the injured.
This situation would be BEST classified as a/an:
A. Unnatural Calamity
B. Natural Calamity
C. Mass Casualty Incident
D. Accidental Disaster
Answer: C. Mass Casualty Incident
Rationale: A mass casualty incident is an event that produces
more casualties than the available medical resources can handle at
one time, requiring the department to prepare to receive multiple
injured persons.
2. The first responders to the scene of disaster would MOST
likely use which of the following tools to separate victims for
easy recognition of those in need of immediate care.
A. Number Codes
B. Triage Tag
C. Category Tags
D. SALT Triage
Answer: B. Triage Tag
Rationale: Triage tags are used by first responders to categorize
and label victims according to the urgency of their need for care,
allowing for easy recognition and prioritization.
3. The ED nurse plans the coding for disaster victims. Which
colors are MOST associated with triage?
1.
1
, Green
2.
3.
Yellow
4.
5.
Black
6.
7.
Blue
8.
9.
White
10.
A.2,3,4,5
B.1,2,3,4,5
C.1,2,3,4
D.1,2,3
Answer: D.1,2,3
Rationale: The standard triage colors are green (minor/delayed),
yellow (urgent), red (emergent/immediate), and black
(deceased/expectant). Blue and white are not standard triage
colors.
4. The ED nurse receives a victim with severe life-
threatening injuries and most likely will not survive. The
victim would be triaged as:
A. Yellow
B. Red
C. Black
D. White
Answer: C. Black
Rationale: The black triage category is for victims who are
deceased or have injuries so severe that they are not expected to
survive, even with treatment (expectant category).
2
,5. One of the victims, a female was brought to the ED crying
hysterically and looking frightened. She exclaims she was
inside her house when the landslide occurred and just barely
escaped. What is the BEST action by the nurse?
A. Refer her to the proper authorities for counselling.
B. Triage her and give appropriate treatment.
C. Call a physician to talk to her.
D. Advise her to go home with a relative.
Answer: B. Triage her and give appropriate treatment.
Rationale: The nurse's first priority is to triage the victim and
provide appropriate treatment. While psychological support is
important, immediate triage and treatment take precedence in a
disaster situation.
Situation - A nine year old male child is hospitalized for
burns on the right arm, right leg and abdomen. The nurse
documents the treatment performed on the child.
6. The nurse determines the extent of burns using the rule
of nines. Which of the following assessment findings should
the nurse document?
A. 18% of the child's body surface is burned.
B. 45% of the child's body surface is burned.
C. 50% of the child's body surface is burned.
D. 25% of the child's body surface is burned.
Answer: B. 45% of the child's body surface is burned.
Rationale: Using the rule of nines for a child: right arm (9%), right
leg (18%), and abdomen (18%) = 45% of the body surface is
burned. In children, the head is proportionally larger and the legs
smaller, but the arm and abdomen percentages remain similar to
adults.
7. The nurse writes a nursing diagnosis for the child which is
the basis of care for the first 24 hours of admission. The
MOST appropriate nursing diagnosis would be
A. Fear and Anxiety
B. Disturbed Body Image
3
, C. Risk for Infection
D. Impaired Mobility
Answer: C. Risk for Infection
Rationale: During the first 24 hours after a burn injury, the patient
is at high risk for infection due to loss of the skin barrier. Preventing
infection is a priority nursing concern.
8. The physician writes an order for the client. Infuse D5
water 500 cc to run for 8 hours. The IV micro set delivers 60
drops per ml. How many drops should the nurse regulate the
flow and record it in the client's chart?
A. 50 drops per minute
B. 62 drops per minute
C. 35 drops per minute
D. 30 drops per minute
Answer: B. 62 drops per minute
Rationale: Using the formula: gtt/min = (volume × drop factor) /
time in minutes. (500 mL × 60 gtt/mL) / (8 hours × 60 min) =
30, = 62.5, rounded to 62 drops per minute.
9. The nurse commits an error in documenting the care of
the burnt child. She consults the charge nurse to find out if
the hospital has an established policy on correcting
documentation errors. Which of the following is an accepted
form for correcting errors?
A. Enclose in parenthesis the erroneous statements, draw a line
across the statement, and make the correct entry above the drawn.
B. Correct the error by applying correction fluid or tape and write
the correct entry over it.
C. Cross through the erroneous word or statement with a double
line, affix your initials, write the phrase "mistaken entry" then write
the correct information.
D. Use the slide rule method. Cross through the erroneous word or
statement with a single line, affix your initials, write the date and
time the correction was made, then write the correct information.
Answer: D. Use the slide rule method. Cross through the
erroneous word or statement with a single line, affix your
initials, write the date and time the correction was made,
then write the correct information.
4
Clients with Physiologic and
Psychosocial Alterations, Part B
Below is the complete Section 4 (Questions 1–100)
in correct exam format, with the question, answer
and a rationale for each.
1. The nurse prepares the department to receive the injured.
This situation would be BEST classified as a/an:
A. Unnatural Calamity
B. Natural Calamity
C. Mass Casualty Incident
D. Accidental Disaster
Answer: C. Mass Casualty Incident
Rationale: A mass casualty incident is an event that produces
more casualties than the available medical resources can handle at
one time, requiring the department to prepare to receive multiple
injured persons.
2. The first responders to the scene of disaster would MOST
likely use which of the following tools to separate victims for
easy recognition of those in need of immediate care.
A. Number Codes
B. Triage Tag
C. Category Tags
D. SALT Triage
Answer: B. Triage Tag
Rationale: Triage tags are used by first responders to categorize
and label victims according to the urgency of their need for care,
allowing for easy recognition and prioritization.
3. The ED nurse plans the coding for disaster victims. Which
colors are MOST associated with triage?
1.
1
, Green
2.
3.
Yellow
4.
5.
Black
6.
7.
Blue
8.
9.
White
10.
A.2,3,4,5
B.1,2,3,4,5
C.1,2,3,4
D.1,2,3
Answer: D.1,2,3
Rationale: The standard triage colors are green (minor/delayed),
yellow (urgent), red (emergent/immediate), and black
(deceased/expectant). Blue and white are not standard triage
colors.
4. The ED nurse receives a victim with severe life-
threatening injuries and most likely will not survive. The
victim would be triaged as:
A. Yellow
B. Red
C. Black
D. White
Answer: C. Black
Rationale: The black triage category is for victims who are
deceased or have injuries so severe that they are not expected to
survive, even with treatment (expectant category).
2
,5. One of the victims, a female was brought to the ED crying
hysterically and looking frightened. She exclaims she was
inside her house when the landslide occurred and just barely
escaped. What is the BEST action by the nurse?
A. Refer her to the proper authorities for counselling.
B. Triage her and give appropriate treatment.
C. Call a physician to talk to her.
D. Advise her to go home with a relative.
Answer: B. Triage her and give appropriate treatment.
Rationale: The nurse's first priority is to triage the victim and
provide appropriate treatment. While psychological support is
important, immediate triage and treatment take precedence in a
disaster situation.
Situation - A nine year old male child is hospitalized for
burns on the right arm, right leg and abdomen. The nurse
documents the treatment performed on the child.
6. The nurse determines the extent of burns using the rule
of nines. Which of the following assessment findings should
the nurse document?
A. 18% of the child's body surface is burned.
B. 45% of the child's body surface is burned.
C. 50% of the child's body surface is burned.
D. 25% of the child's body surface is burned.
Answer: B. 45% of the child's body surface is burned.
Rationale: Using the rule of nines for a child: right arm (9%), right
leg (18%), and abdomen (18%) = 45% of the body surface is
burned. In children, the head is proportionally larger and the legs
smaller, but the arm and abdomen percentages remain similar to
adults.
7. The nurse writes a nursing diagnosis for the child which is
the basis of care for the first 24 hours of admission. The
MOST appropriate nursing diagnosis would be
A. Fear and Anxiety
B. Disturbed Body Image
3
, C. Risk for Infection
D. Impaired Mobility
Answer: C. Risk for Infection
Rationale: During the first 24 hours after a burn injury, the patient
is at high risk for infection due to loss of the skin barrier. Preventing
infection is a priority nursing concern.
8. The physician writes an order for the client. Infuse D5
water 500 cc to run for 8 hours. The IV micro set delivers 60
drops per ml. How many drops should the nurse regulate the
flow and record it in the client's chart?
A. 50 drops per minute
B. 62 drops per minute
C. 35 drops per minute
D. 30 drops per minute
Answer: B. 62 drops per minute
Rationale: Using the formula: gtt/min = (volume × drop factor) /
time in minutes. (500 mL × 60 gtt/mL) / (8 hours × 60 min) =
30, = 62.5, rounded to 62 drops per minute.
9. The nurse commits an error in documenting the care of
the burnt child. She consults the charge nurse to find out if
the hospital has an established policy on correcting
documentation errors. Which of the following is an accepted
form for correcting errors?
A. Enclose in parenthesis the erroneous statements, draw a line
across the statement, and make the correct entry above the drawn.
B. Correct the error by applying correction fluid or tape and write
the correct entry over it.
C. Cross through the erroneous word or statement with a double
line, affix your initials, write the phrase "mistaken entry" then write
the correct information.
D. Use the slide rule method. Cross through the erroneous word or
statement with a single line, affix your initials, write the date and
time the correction was made, then write the correct information.
Answer: D. Use the slide rule method. Cross through the
erroneous word or statement with a single line, affix your
initials, write the date and time the correction was made,
then write the correct information.
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