Class 4 Test Bank 349

The assumption most useful to a nurse planning crisis intervention for any patient is that the patient: a. is experiencing a state of disequilibrium. b. is experiencing a type of mental illness. c. poses a threat of violence to others. d. has a high potential for self-injury.

ANS: A Disequilibrium is the only answer universally true for all patients in crisis. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness. The potential for self-violence or other-directed violence may or may not be a factor in crisis.

A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with post-traumatic stress disorder (PTSD). The nurses highest priority is to screen this soldier for which problem? a. Major depressive disorder b. Bipolar disorder c. Schizophrenia d. Dementia

ANS: A Major depressive disorder frequently co-occurs with PTSD. The incidence of the disorders identified in the distractors is similar to the general population.

While conducting the initial interview with a patient in crisis, the nurse should: a. speak in short, concise sentences. b. convey a sense of urgency to the patient. c. be forthright about time limits of the interview. d. let the patient know that the nurse is in control.

ANS: A Severe anxiety narrows perceptions and concentration. By speaking in short, concise sentences, the nurse enables the patient to grasp what is being said. Conveying urgency will increase the patients anxiety. Letting the patient know who is in control and stating that time is limited are nontherapeutic strategies

A soldier in a combat zone tells the nurse, I saw a child get blown up over a year ago, and now I keep seeing bits of flesh everywhere. I see something red and the visions race back to my mind. Which phenomenon associated with post-traumatic stress disorder (PTSD) is this soldier describing? a. Re-experiencing b. Hyperarousal c. Avoidance d. Psychosis

ANS: A Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with re-experiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.

A victim of spousal violence comes to the crisis center seeking help. The nurse uses crisis intervention strategies that focus on: a. supporting emotional security and reestablishing equilibrium. b. offering long-term resolution of issues precipitating the crisis. c. promoting growth of the individual. d. providing legal assistance.

ANS: A Strategies of crisis intervention are directed toward the immediate cause of the crisis and are aimed at bolstering the emotional security and reestablishing equilibrium, rather than focusing on underlying issues and long-term resolutions. The goal is to return the individual to the precrisis level of function. Crisis intervention is, by definition, short term. Promoting growth is a focus of long-term therapy. Providing legal assistance might be applicable.

A nurse talks with the caregiver of a combat veteran diagnosed with severe traumatic brain injuries. The caregiver says, I dont know how much longer I can do it. My whole life is consumed with taking care of my partner. Select the nurses best response. a. How are you taking care of yourself? b. Lets review your partners diagnostic results. c. I have some web-based programs for you to visit. d. Your partner is lucky to have someone so devoted.

ANS: A The caregiver is the focus of the nurses attention. The caregiver is suffering. The nurse must be empathetic and assess how the caregiver is caring for self. Reassurance and isolated computer activities do not help. The partner is already aware of the diagnostic results.

A professors 4-year-old child has a fever of 101.6 F, diarrhea, and complains of stomach pain. The professor is scheduled to teach three classes today. Which nursing diagnosis best applies to this scenario? a. Decisional conflict b. Unilateral neglect c. Disabled family coping d. Ineffective management of the therapeutic regimen

ANS: A The caregiver is the focus of the nurses attention. The professor is under stress, related to the conflict between his parenting and professional roles. This scenario presents a decisional conflict. No evidence suggests that family coping is disabled or that a therapeutic regimen is not managed. Unilateral neglect refers to the awareness of the body.

A nurse assesses soldiers in a combat zone in Afghanistan. When is it most important for the nurse to screen for signs and symptoms of traumatic brain injury (TBI)? a. After a fall, vehicle crash, or exposure to a blast b. Before departing Afghanistan to return to the United States c. One year after returning to the United States from Afghanistan d. Immediately upon return to the United States from Afghanistan

ANS: A The military estimates that up to 20% of the combat veterans in both Afghanistan and Iraq suffer some degree of TBI. TBI exhibits signs shortly after the injury, and these signs usually resolve in days or weeks. Screening after an exposure to an explosion and before returning to the United States is important.

An adult has cared for a debilitated parent for 10 years. The parents condition recently declined, and the health care provider recommended placement in a skilled care facility. The adult says, Ive always been able to care for my parents. Nursing home placement goes against everything I believe. Successful resolution of this persons crisis will most closely relate to: a. resolving the feelings associated with the threat to the persons self-concept. b. maintaining the ability to identify situational supports in the community. c. relying on the assistance from role models within the persons culture. d. mobilizing automatic relief behaviors by the person.

ANS: A The patients crisis clearly relates to a loss of (or threatened change in) self-concept. Her capacity to care for her parents, regardless of the deteriorating condition, has been challenged. Crisis resolution involves coming to terms with the feelings associated with this loss. Identifying situational supports is relevant but less so than coming to terms with the threat to self-concept. Reliance on lessons from role models can be helpful but is not the primary factor associated with resolution in this case. Automatic relief behaviors are not helpful and are part of the fourth phase of crisis.

A professors 4- year-old child has a temperature of 101.6 F, diarrhea, and complains of stomach pain. The professor is scheduled to teach three classes today. Which actions by the professor demonstrate effective parenting? Select all that apply. a. Telephoning a grandparent to stay with the child at home for the day. b. Telephoning a colleague to teach his classes and staying home with the sick child. c. Taking the child to the university and keeping the child in a private office for the day. d. Taking the child to a daycare center and hoping daycare workers will not notice the child is sick. e. Giving the child one dose of ibuprofen (Motrin) and taking the child to the daycare center

ANS: A, B The correct responses demonstrate fulfillment of the role as a parent. The distractors indicate the professor has not cared for the sick child in an effective way. Taking the child to a daycare center exposes other children to a potential infection. Taking the child to ones office does not keep the child comfortable or provide for the child while the professor is teaching.

An individual says to the nurse, I feel so stressed out lately. I think the stress is affecting my body also. Which somatic complaints are most likely to accompany this feeling? Select all that apply. a. Headache b. Neck pain c. Insomnia d. Anorexia e. Myopia

ANS: A, B, C, D When individuals feel stressed-out, they often have accompanying somatic complaints, especially associated with sleep, eating, and headache or back pain. Changes in vision, such as myopia, would not be expected.

A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would be expected from the driver immediately after this event? Select all that apply. a. Difficulty using a cell phone b. Long-term memory losses c. Fecal incontinence d. Rapid speech e. Trembling

ANS: A, D, E Immediate responses to crisis commonly include shock, numbness, denial, confusion, disorganization, difficulty with decision making, and physical symptoms such as nausea, vomiting, tremors, profuse sweating, and dizziness associated with anxiety. Incontinence and long-term memory losses would not be expected.

A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with post-traumatic stress disorder (PTSD). The soldier says, If theres a loud noise at night, I get under my bed because I think were getting bombed. What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination

ANS: B Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli; although the experience is similar, the more accurate term is flashback because of the diagnosis of PTSD. Auditory hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this experience is stimulated by an actual environmental sound.

A patient comes to the clinic with superficial cuts on the left wrist. The patient paces around the room sobbing but cringes when approached and responds to questions with only shrugs or monosyllables. Select the nurses best initial statement to this patient. a. Everything is going to be all right. You are here at the clinic, and the staff will keep you safe. b. I see you are feeling upset. I am going to stay and talk with you to help you feel better. c. You need to try to stop crying so we can talk about your problems. d. Lets set some guidelines and goals for your visit here.

ANS: B A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate the use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patients safety. The incorrect responses use nontherapeutic techniques, including false reassurance and giving advice.

An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The patient told the parents about the uncles behavior, but the parents did not believe the adolescent. What type of crisis exists? a. Maturational b. Adventitious c. Situational d. Organic

ANS: B An adventitious crisis is a crisis of disaster that is not a part of everyday life; it is unplanned or accidental. Adventitious crises include natural disasters, national disasters, and crimes of violence. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. Situational crisis arises from an external source such as a job loss, divorce, or other loss affecting self-concept or self-esteem. Organic is not a type of crisis.

As part of the stress response, the HPA axis is stimulated. Which structures make up this system? a. Hippocampus, parietal lobe, and amygdala b. Hypothalamus, pituitary gland, and adrenal glands c. Hind brain, pyramidal nervous system, and anterior cerebrum d. Hepatic artery, parasympathetic nervous system, and acoustic nerve

ANS: B As part of the physiologic response of stress, the hypothalamus stimulates the HPA axis, which is made up of the hypothalamus, pituitary gland, and adrenal glands.

Cortisol is released in response to a patients prolonged stress. Which initial effect would the nurse expect to result from the increased cortisol level? a. Diuresis and electrolyte imbalance b. Focused and alert mental status c. Drowsiness and lethargy d. Restlessness and anxiety

ANS: B Cortisol is the primary stress hormone and is released in response to prolonged stress. Cortisol helps supply cells with amino acids and fatty acids for energy supply, as well as diverting glucose from muscles for use by the brain. As a result, the brain stays alert and focused. The distractors present effects that would not be expected.

Which scenario best demonstrates an example of eustress? An individual: a. loses a beloved family pet. b. prepares to take a 1 week vacation to a tropical island with a group of close friends. c. receives a bank notice there were insufficient funds in their account for a recent rent payment. d. receives notification that their current employer is experiencing financial problems and some workers will be terminated.

ANS: B Eustress is beneficial stress; it motivates people to develop skills they need to solve problems and meet personal goals. Positive life experiences produce eustress. Going on a tropical vacation is an exciting, relaxing experience and an example of eustress. Losing the family pet, worrying about employment security, and having financial problems are examples of distress, a negative experience that drains energy and can lead to significant emotional problems.

A patient comes to the crisis center saying, Im in a terrible situation. I dont know what to do. The triage nurse can initially assume that the patient is: a. suicidal. b. anxious and fearful. c. misperceiving reality. d. potentially homicidal.

ANS: B Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed.

A nurse assesses an adult experiencing a crisis. An appropriate question for the nurse to ask to determine situational support is: a. Has anything upsetting occurred in the past few days? b. Who can be helpful to you during this time? c. How does this problem affect your life? d. What led you to seek help at this time?

ANS: B Only the correct answer focuses on situational support. The incorrect options focus on the patients perception of the precipitating event.

Which situation demonstrates the use of primary care related to crisis intervention? a. Implementing suicide precautions for a patient with depression. b. Teaching stress reduction techniques to a beginning student nurse. c. Assessing coping strategies used by a patient who has attempted suicide. d. Referring a patient with schizophrenia to a partial hospitalization program

ANS: B Primary crisis intervention promotes mental health and reduces mental illness. The incorrect options are examples of secondary or tertiary interventions.

A patient diagnosed with liver failure has been on the transplant waiting list 8 months. The patient says, Why is it taking so long to have the surgery? Maybe Im meant to die for all the bad things Ive done. The nurse should document the patients comment in which section of the assessment? a. Physical b. Spiritual c. Financial d. Psychological

ANS: B Stress can be evident in a persons spirituality. This patients comment indicates questioning of ones place in the universe and consequences for wrongdoing, both of which are elements of spirituality. Stress can be related to psychological, physical, or psychosocial well-being, but spirituality is the best answer.

A woman says, I cant take anymore! Last year my husband had an affair and now we dont communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said shes quitting college. If this persons immediate family is unable to provide sufficient situational support, the nurse should: a. suggest hospitalization for a short period. b. ask what other relatives or friends are available for support. c. tell the patient, You must be strong. Dont let this crisis overwhelm you. d. foster insight by relating the present situation to earlier situations involving loss.

ANS: B The assessment of situational supports should continue. Although the patients nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually nontherapeutic.

During the initial interview at the crisis center, a patient says, Ive been served with divorce papers. Im so upset and anxious that I cant think clearly. What could the nurse say to assess personal coping skills? a. What would you like us to do to help you feel more relaxed? b. In the past, how did you handle difficult or stressful situations? c. Do you think you deserve to have things like this happen to you? d. I can see you are upset. You can rely on us to help you feel better.

ANS: B The correct answer is the only option that assesses coping skills. The incorrect options offer unrealistic reassurance, are concerned with self-esteem, and ask the patient to decide on treatment at a time when he or she cannot think clearly.

A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with post-traumatic stress disorder (PTSD). Which comment by the soldier requires the nurses immediate attention? a. Its good to be home. I missed my family and friends. b. I saw my best friend get killed by a roadside bomb. It should have been me instead. c. Sometimes I think I hear bombs exploding, but its just the noise of traffic in my hometown. d. I want to continue my education but Im not sure how I will fit in with other college students.

ANS: B The correct response indicates the soldier is thinking about death and feeling survivors guilt. These emotions may accompany suicidal ideation, which warrants the nurses followup assessment. Suicide is a high risk among military personnel diagnosed with PTSD. One distractor indicates flashbacks, which is common with individuals with PTSD but is not solely indicative of further problems. The other distractors are normal emotions associated with returning home and change.

Which communication technique is used more in crisis intervention than traditional counseling? a. Role modeling b. Giving direction c. Information giving d. Empathic listening

ANS: B The nurse working in crisis intervention must be creative and flexible in looking at the patients situation and suggesting possible solutions to the patient. Giving direction is part of the active role a crisis intervention therapist takes. The other options are used equally in crisis intervention and traditional counseling roles.

An adult comes to the crisis clinic after being terminated from a job of 15 years. The patient says, I dont know what to do. How can I get another job? Who will pay the bills? How will I feed my family? Which nursing diagnosis applies? a. Hopelessness b. Powerlessness c. Chronic low self-esteem d. Disturbed thought processes

ANS: B The patient describes feelings of the lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patients thought processes are not shown to be altered at this point.

After celebrating a 40th birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? a. Reactive b. Situational c. Maturational d. Adventitious

ANS: C Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual, such as divorce and job loss. No classification called reactive crisis exists. Adventitious crises occur when disasters such as natural disasters (e.g., floods, hurricanes), war, or violent crimes disrupt coping styles.

A woman says, I cant take anymore! Last year my husband had an affair and now we dont communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said shes quitting college. What type of crisis is this person experiencing? a. Maturational b. Adventitious c. Situational d. Recurring

ANS: C A situational crisis arises from an external source and involves a loss of self-concept or selfesteem. An adventitious crisis is a crisis of disaster, such as a natural disaster or crime of violence. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists.

A soldier who served in a combat zone returned to the United States. The soldiers spouse complains to the nurse, We had planned to start a family, but now he wont talk about it. He wont even look at children. The spouse is describing which symptom associated with post-traumatic stress disorder (PTSD)? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

ANS: C Physiologic reactions to reminders of the event include a persistent avoidance of the stimuli associated with the trauma; the individual avoids talking about the event or avoids activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. No evidence suggests that this soldier is having a hyperarousal reaction or is re-experiencing war-related traumas. Psychosis is not evident.

Which agency provides coordination in the event of a terrorist attack? a. U.S. Food and Drug Administration (FDA) b. Environmental Protection Agency (EPA) c. National Incident Management System (NIMS) d. Federal Emergency Management Agency (FEMA)

ANS: C The NIMS provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations.

A person with a fear of heights drives across a high bridge. Which division of the autonomic nervous system is stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system

ANS: C The autonomic nervous system is made up of the sympathetic (fight-or-flight response) and parasympathetic (relaxation response) nervous systems. In times of stress, the sympathetic nervous system is stimulated. A person fearful of heights would experience stress associated with the experience of driving across a high bridge. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system.

A patient visiting the crisis clinic for the first time asks, How long will I be coming here? The nurses reply should consider that the usual duration of crisis intervention is _______ weeks. a. 1 to 2 b. 3 to 4 c. 4 to 6 d. 6 to 12

ANS: C The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 6 weeks. If the crisis is not resolved by that time, the individual usually adopts dysfunctional behaviors that reduce anxiety without solving the problem. Crisis intervention can shorten the duration.

A person with a fear of heights drives across a high bridge. Which structure will stimulate a response from the autonomic nervous system? a. Thalamus b. Parietal lobe c. Hypothalamus d. Pituitary gland

ANS: C The individual will find this experience stressful. The hypothalamus functions as the command-and-control center when receiving stressful signals. The hypothalamus responds to signals of stress by engaging the autonomic nervous system. The parietal lobe is responsible for the interpretation of other sensations. The thalamus processes messages associated with pain and wakefulness. The pituitary gland may be involved in other aspects of the persons response but would not stimulate the autonomic nervous system.

At the last contracted visit in the crisis intervention clinic, an adult says, Ive emerged from this a stronger person. You helped me feel like my life is back in balance. The nurse responds, I think it would be worthwhile to have two more sessions to explore why your reactions were so intense. Which analysis applies? a. The patient is experiencing transference. b. The patient demonstrates a need for continuing support. c. The nurse is having difficulty terminating the relationship. d. The nurse is empathizing with the patients feelings of dependency.

ANS: C The nurses remark is clearly an invitation to work on other problems and prolong contact with the patient. The focus of crisis intervention is on the problem that precipitated the crisis, not other issues. The scenario does not describe transference. The patients need for continuing support is not demonstrated in the scenario. The scenario does not describe dependency needs.

An adult tells the nurse, I cant take anymore! Last year my husband had an affair and now we dont communicate. Three months ago, I found a lump in my breast. Yesterday my daughter told me shes quitting college and moving in with her boyfriend. What is the priority nursing diagnosis? a. Fear, related to impending breast surgery b. Deficient knowledge, related to breast lesion c. Ineffective coping, related to perceived loss of daughter d. Impaired verbal communication, related to spousal estrangement

ANS: C This nursing diagnosis is the priority because it reflects the precipitating event associated with the patients crisis. Data are not present to make the other diagnoses of Deficient knowledge, Fear, or Impaired verbal communication.

Which experiences are most likely to precipitate post-traumatic stress disorder (PTSD)? Select all that apply. a. An 8-year-old child watches an R-rated movie with both parents. b. A young adult jumps from a bridge with a bungee cord with a best friend. c. An adolescent is kidnapped and held for 2 years in the home of a sexual predator. d. A passenger is in a bus that overturns on a sharp curve in the road, tumbling down an embankment. e. An adult is trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

ANS: C, D, E PTSD usually follows a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture or kidnapping, military combat, sexual assault, and natural disasters such as floods, tornados, earthquakes, and tsunamis; human disasters such as a bus or elevator accident or crime-related events such being taken hostage are additional examples. The common element in these experiences is the individuals extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumping by adolescents is part of the developmental task and might be frightening but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way.

A nurse assesses the health status of soldiers returning from Afghanistan. Screening will be a priority for signs and symptoms of which health problems? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Seasonal affective disorder e. Post-traumatic stress disorder

ANS: C, E TBI and PTSD each occur in approximately 20% of soldiers returning from Afghanistan. Some soldiers have both problems. The incidence of disorders identified in the distractors would be expected to parallel the general population.

A patient comes to the clinic with superficial cuts on the left wrist. The patient is pacing and sobbing. After a few minutes with the nurse, the patient is calmer. What should the nurse ask to determine the patients perception of the precipitating event? a. Tell me why you were crying. b. How did your wrist get injured? c. How can I help you feel more comfortable? d. What was happening just before you started feeling this way?

ANS: D A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events permits the assessment of the precipitating event. Asking why questions is a nontherapeutic communication technique.

Which health care worker should be referred to critical incident stress debriefing? a. Nurse who works at an oncology clinic where patients receive chemotherapy b. Case manager whose patients are seriously mentally ill and are being cared for at home c. Health care employee who worked 8 hours at the information desk of an intensive care unit d. Emergency medical technician (EMT) who treated victims of a car bombing at a department store

ANS: D Although each of the individuals mentioned experiences job-related stress on a daily basis, the person most in need of critical incident stress debriefing is the EMT, who experienced an adventitious crisis event by responding to a bombing and provided care to victims of trauma.

A troubled adolescent opened fire in a high school cafeteria, fatally shooting three people and injuring many others. Hundreds of parents come to the high school after hearing the news reports. After the police arrest the shooter, which action should occur next? a. Ask the police to encircle the school campus with yellow tape to prevent parents from entering. b. Announce over the loudspeakers, The campus is now secure. Please return to your classrooms. c. Require parents to pass through metal detectors and then allow them to look for their children in the school. d. Designate zones according to the alphabet, and direct students to the zones based on their surnames to facilitate reuniting them with their parents.

ANS: D Chaos is likely among students and desperate parents. A directive approach is best. Once the scene is secure, creative solutions are needed. Creating zones by letters of the alphabet helps anxious parents and their children to unite. Preventing parents from uniting with their children would further incite the situation.

A woman says, I cant take anymore! Last year my husband had an affair and now we dont communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said shes quitting college. What is the nurses priority assessment? a. Identifying measures useful to help improve the couples communication b. Discussing the patients feelings about the possibility of having a mastectomy c. Determining whether the husband is still engaged in an extramarital affair d. Clarifying what the patient means by I cant take it anymore!

ANS: D During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the patient sought help.

A soldier returned home last year after deployment to a war zone. The soldiers spouse complains, We were going to start a family but now he wont talk about it. He will not look at children. I wonder if were going to make it as a couple. Select the nurses best response. a. Post-traumatic stress disorder often changes a persons sexual functioning. b. I encourage you to continue to participate in social activities where children are present. c. Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior. d. Post-traumatic stress disorder often strains relationships. I will suggest some community resources for help and support.

ANS: D PSTD precipitates changes that often lead to divorce. Providing support to both the veteran and spouse is important. Confrontation will not be effective. Although providing information is important, ongoing support is more effective.

A soldier served in combat zones in Iraq in 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of post-traumatic stress disorder (PTSD)? a. Immediately upon return to the United States from Afghanistan b. Before departing Afghanistan to return to the United States c. One year after returning from Afghanistan d. Screening should be ongoing

ANS: D PTSD can have a long lag timemonths to years. Screening should be ongoing.

A woman says, I cant take anymore! Last year my husband had an affair and now we dont communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said shes quitting college and moving in with her boyfriend. Which issue should be the focus for crisis intervention? a. Possible mastectomy b. Disordered family communication c. Effects of the husbands infidelity d. Coping with the reaction to the daughters events

ANS: D The focus of crisis intervention is on the most recent problemthe straw that broke the camels back. The patient has coped with the breast lesion, the husbands infidelity, and the disordered communication. Disequilibrium occurs only with the introduction of the daughter leaving college and moving.

An adult seeks counseling after the spouse is murdered. The adult angrily says, I hate the beast that did this. It has ruined my life. During the trial, I dont know what Ill do if the jury doesnt return a guilty verdict. What is the nurses highest priority question? a. Would you like to talk to a psychiatrist about some medication to help you cope during the trial? b. What resources do you need to help you cope with this situation? c. Do you have enough support from your family and friends? d. Are you having thoughts of hurting yourself or others?

ANS: D The highest nursing priority is safety. The nurse should assess suicidal and homicidal potentials. The incorrect options may be important but not the highest priority.

After completing the contracted number of visits to the crisis clinic, an adult says, Ive emerged from this as a stronger person. You supported me while I worked through my feelings of loss and helped me find community resources. Im benefiting from a support group. The nurse can evaluate the patients feelings about the care received as: a. not at all satisfied. b. somewhat satisfied. c. moderately satisfied. d. very satisfied.

ANS: D The patient mentions a number of indicators that suggest a high degree of satisfaction with the Nursing Outcomes Classification of patient satisfaction: psychological care. No indicators express low-to-moderate satisfaction.

A patient is brought to the emergency department after a motorcycle accident. The patient is alert, responsive, and diagnosed with a broken leg. The patients vital signs are temperature (T), 98.6 F; pulse (P), 72 beats per minute (bpm); and respirations (R), 16 breaths per minute. After being informed that surgery is required for the broken leg, which vital sign readings would be expected? a. T, 98.6; P, 64; R, 14 b. T, 98.6; P, 68; R, 12 c. T, 98.6; P, 62; R, 16 d. T, 98.6; P, 84; R, 22

ANS: D The patient would experience stress associated with the anticipation of surgery. In times of stress, the sympathetic nervous system takes over (fight-or-flight response) and sends signals to the adrenal glands, thereby releasing norepinephrine. The circulating norepinephrine increases the heart rate. Respirations increase, bringing more oxygen to the lungs.

Which scenario is an example of an adventitious crisis? a. Death of a child from sudden infant death syndrome b. Being fired from a job because of company downsizing c. Retirement of a 55-year-old d. Riot at a rock concert

ANS: D The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of situational or maturational crises.

A soldier returned 3 months ago from Afghanistan and was diagnosed with post-traumatic stress disorder (PTSD). Which social event would most likely be disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. Family outing to the seashore d. Fireworks display on July 4th

ANS: D exploding noises associated with fireworks are most likely to provoke exaggerated responses for this soldier. The distractors are not associated with offensive sounds.