,Arizona College NUR 445 Exam 4 | Acute & Chronic
Health Disruptions Adult III (2026) Q&A
1. A nurse is assisting with triaging clients following an explosion. Which client should the
nurse identify as the highest priority?
A) A conscious adult client who has second-degree burns on both lower legs; respiratory
rate is 32/min
B) A client who is unresponsive with a penetrating head wound
C) A client who has a fractured femur and is in severe pain
D) A client who has a minor laceration and is ambulatory
Correct Answer: A conscious adult client who has second-degree burns on both lower
legs; respiratory rate is 32/min
Rationale: In disaster triage using the START method, immediate priority is given to
clients who require life-saving intervention but have a high probability of survival. A
respiratory rate over 30/min indicates the need for immediate intervention, and the client's
burns require urgent care, making them the highest priority. An unresponsive client with a
penetrating head wound would be categorized as expectant (black tag) or deceased. The
fractured femur and minor laceration are lower priorities.
2. A charge nurse is discussing the phases of community response to a disaster with
nursing staff. Which statement indicates an understanding of the heroic phase?
A) "Personnel are willing to work in dangerous conditions to provide care."
B) "The community begins to focus on rebuilding and recovery."
C) "There is a period of disillusionment and blaming."
D) "Normal community functioning is restored."
,Correct Answer: "Personnel are willing to work in dangerous conditions to provide
care."
Rationale: The heroic phase occurs immediately after a disaster, characterized by
altruistic behavior and a willingness to help others despite personal risk. The honeymoon
phase follows, then the disillusionment phase, and finally the reconstruction phase.
3. A nurse is implementing the Simple Triage and Rapid Treatment (START) method during
a mass casualty event. Which intervention is appropriate during the triage process?
A) Administering intravenous fluids
B) Direct pressure to control bleeding
C) Performing a full head-to-toe assessment
D) Obtaining a detailed medical history
Correct Answer: Direct pressure to control bleeding
Rationale: The START triage method allows for only two interventions during the triage
process: direct pressure to control bleeding and opening the airway using a head-tilt chin-
lift or jaw-thrust maneuver. Full assessments and medical histories are deferred until after
triage.
4. A nurse is caring for a client following a motor vehicle crash. Which finding indicates the
need for immediate intervention?
A) Heart rate of 110 beats/min
B) Clear fluid leaking from the nose
C) Blood pressure of 110/70 mm Hg
D) Respiratory rate of 20 breaths/min
Correct Answer: Clear fluid leaking from the nose
, Rationale: Clear fluid leaking from the nose may indicate a basilar skull fracture with
cerebrospinal fluid leak. This requires immediate intervention and cervical spine
precautions to prevent further injury. Tachycardia and borderline blood pressure are
concerning but not as immediately life-threatening.
5. A nurse is assessing a client with a suspected cervical spine injury. Which action should
the nurse take first?
A) Obtain a full set of vital signs
B) Apply a rigid cervical collar
C) Maintain manual stabilization of the head and neck
D) Perform a neurological assessment
Correct Answer: Maintain manual stabilization of the head and neck
Rationale: Manual stabilization of the head and neck is the first priority in a client with a
suspected cervical spine injury to prevent further damage to the spinal cord. A rigid collar
is applied after manual stabilization is established.
6. A nurse is caring for a client with a chest tube following a traumatic injury. Which finding
requires immediate intervention?
A) Continuous bubbling in the water-seal chamber
B) Fluctuation of the fluid level in the water-seal chamber with respirations
C) Drainage of 50 mL of serosanguineous fluid in the first hour
D) Occasional bubbling in the suction control chamber
Correct Answer: Continuous bubbling in the water-seal chamber
Health Disruptions Adult III (2026) Q&A
1. A nurse is assisting with triaging clients following an explosion. Which client should the
nurse identify as the highest priority?
A) A conscious adult client who has second-degree burns on both lower legs; respiratory
rate is 32/min
B) A client who is unresponsive with a penetrating head wound
C) A client who has a fractured femur and is in severe pain
D) A client who has a minor laceration and is ambulatory
Correct Answer: A conscious adult client who has second-degree burns on both lower
legs; respiratory rate is 32/min
Rationale: In disaster triage using the START method, immediate priority is given to
clients who require life-saving intervention but have a high probability of survival. A
respiratory rate over 30/min indicates the need for immediate intervention, and the client's
burns require urgent care, making them the highest priority. An unresponsive client with a
penetrating head wound would be categorized as expectant (black tag) or deceased. The
fractured femur and minor laceration are lower priorities.
2. A charge nurse is discussing the phases of community response to a disaster with
nursing staff. Which statement indicates an understanding of the heroic phase?
A) "Personnel are willing to work in dangerous conditions to provide care."
B) "The community begins to focus on rebuilding and recovery."
C) "There is a period of disillusionment and blaming."
D) "Normal community functioning is restored."
,Correct Answer: "Personnel are willing to work in dangerous conditions to provide
care."
Rationale: The heroic phase occurs immediately after a disaster, characterized by
altruistic behavior and a willingness to help others despite personal risk. The honeymoon
phase follows, then the disillusionment phase, and finally the reconstruction phase.
3. A nurse is implementing the Simple Triage and Rapid Treatment (START) method during
a mass casualty event. Which intervention is appropriate during the triage process?
A) Administering intravenous fluids
B) Direct pressure to control bleeding
C) Performing a full head-to-toe assessment
D) Obtaining a detailed medical history
Correct Answer: Direct pressure to control bleeding
Rationale: The START triage method allows for only two interventions during the triage
process: direct pressure to control bleeding and opening the airway using a head-tilt chin-
lift or jaw-thrust maneuver. Full assessments and medical histories are deferred until after
triage.
4. A nurse is caring for a client following a motor vehicle crash. Which finding indicates the
need for immediate intervention?
A) Heart rate of 110 beats/min
B) Clear fluid leaking from the nose
C) Blood pressure of 110/70 mm Hg
D) Respiratory rate of 20 breaths/min
Correct Answer: Clear fluid leaking from the nose
, Rationale: Clear fluid leaking from the nose may indicate a basilar skull fracture with
cerebrospinal fluid leak. This requires immediate intervention and cervical spine
precautions to prevent further injury. Tachycardia and borderline blood pressure are
concerning but not as immediately life-threatening.
5. A nurse is assessing a client with a suspected cervical spine injury. Which action should
the nurse take first?
A) Obtain a full set of vital signs
B) Apply a rigid cervical collar
C) Maintain manual stabilization of the head and neck
D) Perform a neurological assessment
Correct Answer: Maintain manual stabilization of the head and neck
Rationale: Manual stabilization of the head and neck is the first priority in a client with a
suspected cervical spine injury to prevent further damage to the spinal cord. A rigid collar
is applied after manual stabilization is established.
6. A nurse is caring for a client with a chest tube following a traumatic injury. Which finding
requires immediate intervention?
A) Continuous bubbling in the water-seal chamber
B) Fluctuation of the fluid level in the water-seal chamber with respirations
C) Drainage of 50 mL of serosanguineous fluid in the first hour
D) Occasional bubbling in the suction control chamber
Correct Answer: Continuous bubbling in the water-seal chamber
