Name: Rou’z Ven E.

Semilla BSN -A1 Date: 08-16-2021

NURSING CARE OF CLIENTS WITH LIFE THREATENING CONDITIONS

CHECK FOR UNDERSTANDING (25 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 25 minutes for this activity:

Multiple Choice

1. You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The
date of the patient’s last tetanus shot is unknown. Which of the following is the priority nursing diagnosis?

A. Risk for Impaired Mobility related to potential tendon damage.

B. Risk for Infection related to organisms specific to cat bites.
C. Ineffective Health Maintenance related to immunization status.
D. Impaired Skin Integrity related to puncture wounds.
ANSWER: C
RATIO: Cat’s mouths contain a virulent organism. Pasteurella multocida. that can lead to septic arthritis or bacteremia.
Options A and D: There is also a risk for tendon damage due to deep puncture wounds. These wounds are usually not
sutured. Option C: A tetanus shot can be given before discharge.

2. You are assigned to telephone triage. A patient who was stung by a common honey bee calls for advice, reports pain
and localized swelling, but denies any respiratory distress or other systemic signs of anaphylaxis. What is the action that
you should direct the caller to perform?
A. Remove the stinger by scraping.
B. Take an oral antihistamine
C. Call 911.
D. Apply a cool compress.
ANSWER: A
RATIO: The stinger will continue to release venom into the skin, so prompt removal of the stinger is advised. Cool
compresses and antihistamines can follow. The caller should be further advised about symptoms that require 911
assistance.

3. A client calls the office of his primary care health care provider and tells the nurse that he was just stung by a
bumblebee while gardening. The client is afraid of a severe reaction, because the client's neighbor experienced such a
reaction just 1 week ago. The appropriate nursing action is to: experienced such a reaction just 1 week ago. The
appropriate nursing action is to:
A. Advise the client to soak the site in hydrogen peroxide.
B. Ask the client if he ever sustained a bee sting in the past.
C. Tell the client to call an ambulance for transport to the emergency room.
D. Tell the client not to worry about the sting unless difficulty with breathing occurs
ANSWER: B
RATIO: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen.
Therefore, the appropriate action would be to ask the client if he ever received a bee sting in the past.

4. The camp nurse prepares to instruct a group of children about Lyme disease. Which of the following information would
the nurse include in the instructions?
A. Lyme disease is caused by a tick carried by deer.
B. Lyme disease is caused by contamination from cat feces.
C. Lyme disease can be contagious by skin contact with an infected individual.
D. Lyme disease can be caused by the inhalation of spores from bird droppings.
ANSWER: A
RATIO: Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer,
persons bitten by Ixodes ticks can be infected with the spirochete borrelia burgdorferi lyme disease cannot be transmitted
from one person to another.Toxoplasmosis is caused from the ingestion of cysts from contaminated cat feces.
Histoplasmosis is caused by the inhalation of spores from bat or bird droppings

5. The client is diagnosed with stage I of Lyme disease. The nurse assesses the client for which characteristic of this
stage?
A. Arthralgias
B. Flu-like symptoms
C. Enlarged and inflamed joints
 D. Signs of neurological disorders
ANSWER: B
RATIO: The hallmark of stage I is the development of a skin rash within 2 to 30 days of infection, generally at the site of
the tick bite. The rash develops into a concentric ring, giving it a bullseye appearance. The lesion enlarges up to 50 to 60
cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flu-like
symptoms that last 7 to 10 days; these symptoms may reoccur later. Neurological deficits occur in stage II. Arthralgias
and joint enlargements are most likely to occur in stage III.

6. A camp nurse is providing snakebite prevention tips. Which statement by a client camper indicates a need for additional
education?
A. "A dead snake is a safe snake."
B. "Snakes are most active on warm nights."
C. "Snakes should be transported in sealed glass containers."
D. "Venomous snakes are not good pets."
ANSWER: A
RATIO: Never touch a snake, even if you think it is dead. The fangs of a dead snake can still inject venom.

7. A 12-year-old client comes to the emergency department (ED) after being bitten by a scorpion at a local petting zoo.
Which action does the nurse perform first?
A. Administers a tetanus shot
B. Applies an ice pack to the sting site
C. Assesses the client's vital signs
D. Calls the poison control center
ANSWER: C
RATIO: The first priority is vital signs assessment and continuous monitoring for several hours. This is done in the
hospital emergency department or critical care unit to enable rapid intervention if symptoms progress.

8. A nurse is teaching a class of park rangers-in-training about prioritizing care for clients who have received snakebites.
Which ranger's statement demonstrates a need for further clarification?
A. ''Do not allow the client to ingest any alcohol or caffeine.''
B. ''The extremity should be kept below the level of the heart.''
C. ''The first priority is to move the client to a safe area away from the snake.''
D. ''You should first place a tourniquet above the bite.''
ANSWER: D
RATIO: If transportation and treatment are delayed, a 2- to 4-cm constricting band may be applied proximal to an
extremity wound to slow venom circulation via lymphatic flow. It should not be used as a tourniquet, however. This could
worsen local tissue necrosis by retaining venom in the tissues.

9. While on the playground, a school child is stung by a bee, resulting in redness and swelling. The school nurse is nearby
when it happens. What does the nurse do first?
A. Applies an ice pack to the stinger
B. Gently scrapes out the stinger with a credit card
C. Injects the child with an epinephrine pen (Epi-Pen auto-injector)
D. Removes the bee and saves it for evidence of the sting
ANSWER: B
RATIO: The commonly preferred method is to remove the stinger by gently scraping or brushing it off with the edge of a
knife blade, credit card, or needle. However, it is important to realize that the method used to remove the stinger is not as
relevant as the speed of removal

10. A young man is brought to the Emergency Department after receiving multiple fire ant bites while working in his yard.
Although initially alert and oriented, he begins to develop wheezing and an itchy throat. He complains of nausea and
severe anxiety. The ED nurse should prepare to administer all of the following for initial treatment EXCEPT:

A. Adrenaline
B. Antibiotic
C. Oxygen
D. Antihistamines
ANSWER: B
RATIO: The nurse should recognize that these signs and symptoms indicate possible anaphylaxis following the fire ant
bites. Antibiotics are not indicated for the initial treatment of anaphylaxis. They may be necessary at a future time if the
ant bites become infected. Adrenaline, oxygen, and antihistamines will help reduce some of the symptoms the patient is
experiencing. The nurse should also be prepared for emergency intubation if the respiratory problems increase and result
in respiratory distress.