2025 QUESTIONS AND ANSWERS
Which triage category refers to life-threatening or potentially life-threatening injury or illness
requiring immediate treatment?
a. Immediate
b. Non acute
c.Emergent
d. Urgent - ANS Emergent
Which phase of the psychological reaction to rape is characterized by fear and flashbacks?
a. Heightened anxiety phase
b. Reorganization phase
c. Acute disorganization phase
d.Denial phase - ANS Heightened anxiety phase
A nurse is providing an in-service program for fellow emergency nurses about hypothermia and
rewarming methods used. The nurse determines that the presentation was successful when the
group identifies which of the following as a passive-active rewarming method?
a. Over-the-bed heaters
b. Warmed humidified oxygen by ventilator
c. Forced warm air blankets
d. Cardiopulmonary bypass - ANS Over-the-bed heaters
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,Explanation:
Passive active rewarming uses over-the-bed heaters to the extremities and increases blood flow
to the acidotic, anaerobic extremities. Cardiopulmonary bypass and warm humidified oxygen by
ventilator are examples of active core (internal) rewarming methods. Forced warm air blankets
are examples of active external rewarming methods.
A client arrives at the emergency department and is experiencing a severe allergic reaction to a
bee sting. The client received treatment and is being discharged. Which client statement
indicates that additional teaching about exposure prevention is needed?
a. "I should always wear something on my feet when I'm outside."
b. "If a bee comes near me, I should stay still."
c. "Brightly colored clothes help to ward off bees."
d. "I need to avoid using perfumes and scented soaps when I'm going outside." -
ANS "Brightly colored clothes help to ward off bees."
Explanation:
To prevent insect stings, the client should avoid wearing brightly colored clothing because it
attracts bees. The client should wear covering on the feet and avoid going barefoot because
yellow jackets nest and pollinate on the ground. Staying still or motionless reduces the
likelihood of being stung. Perfumes and scented soaps attract bees and should be avoided.
A patient is brought to the emergency department and diagnosed with decompression sickness.
The nurse interprets this as indicating that the patient most likely has been involved with which
of the following?
a. Diving in an ocean
b. Running a race in hot humid weather
c. Working in a chemical plant
d. Swimming in a lake - ANS Diving in an ocean
Explanation:
Decompression sickness occurs when patients have engaged in diving in a lake or ocean or high-
altitude flying or flying in a commercial aircraft within 24 hours of diving. Swimming in a lake
could lead to a near-drowing episode. Running a race in hot humid weather would increase a
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, person's risk for heat stroke. Working in a chemical plant would increase the risk for chemical
burns.
Which guideline is appropriate for a nurse to implement while helping family members cope
with the sudden death of a loved one?
a. Show acceptance of the body by touching it, giving the family permission to touch.
b. Inform the family that the client has passed on.
c. Provide details of the factors attendant to the sudden death.
d. Obtain orders for sedation for family members. - ANS Show acceptance of the body by
touching it, giving the family permission to touch.
Explanation:
The nurse should encourage the family to view and touch the body if they wish, since this
action helps the family to integrate the loss. The nurse should avoid using euphemisms such as
"passed on." The nurse should avoid giving sedation to family members, because this may mask
or delay the grieving process. The nurse should avoid volunteering unnecessary information
(e.g., client was drinking at the time of the accident).
The nurse is caring for a victim of a sexual assault. The client is fearful and experiencing
flashbacks. The nurse recognizes that the client is experiencing which phase of the
psychological reaction to rape?
a. Reorganization phase
b. Denial phase
c. Heightened anxiety phase
d.Acute disorganization phase - ANS Heightened anxiety phase
Explanation:
During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and
psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is
characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is
characterized by an unwillingness to talk. The reorganization phase occurs when the incident is
put into perspective. Some clients never fully recover from rape trauma.
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