Psych Nursing Quiz 5

How much time does it usually take for a crisis to sell-resolve? 1. 1 to 10 days 2. 1 to 3 weeks 3. 4 to 6 weeks 4. 3 to 4 months

3. 4 to 6 weeks Rationale At 4 to 6 weeks, the individual is making accommodations and adjustments to relieve anxiety, and the crisis is no longer a crisis. These adjustments usually cannot be made in less time, but taking 3 to 4 months would not be tolerable.

An employee is working to manage several similar projects to meet a deadline. Which type of stress is this employee experiencing? 1. Acute 2. Autonomic 3. Chronic 4. Eustress

4. Eustress Rationale The employee is experiencing eustress, normal healthy stress. Acute describes stress during a brief period of time. Autonomic is the branch of the nervous system responsible for the body's response to stress. Chronic stress is long-term stress.

Which form of crises may occur as an individual moves from one developmental level to another? 1. Reactive 2. Adventitious 3. Situational 4. Maturational

4. Maturational Rationale Maturational crises are normal states in growth and development in which specific new maturational tasks must be learned when old coping mechanisms are no longer effective. A situational crisis arises from events that are extraordinary, external rather than internal, and often unanticipated. An adventitious crisis is not a part of everyday like; it results from events that are unplanned and may be accidental, caused by nature, or human-made. Reactive is not a term used to identify a type of crisis. p. 326

What is the highest priority of care for a client in emotional crisis? 1. Reduction of anxiety 2. Development of new coping skills 3. Prevention of boundary blurring 4. Promoting client safety

4. Promoting client safety Rationale The nurse's initial task is to promote safety by assessing the client's potential for suicide or homicide. Reduction of anxiety, development of new coping skills, and prevention of boundary blurring are all important components of the care plan, but safety of the client takes the highest priority.

Which behavior best supports the diagnosis of posttraumatic stress disorder (PTSD) in a 4- year-old child? 1. Overeating 2. Hypervigilance 3. Perfectionism 4. Passivity

2. Hypervigilance Rationale Child abuse may be associated with irritability and hypervigilance. Overeating, perfectionism, and passivity are not typically associated with PTSD in children.

A nurse is planning interventions for a veteran who is reporting difficulty sleeping. When considering the client's history, which data is most relevant to the development of posttraumatic stress disorder (PTSD)? 1. Family history of depression 2. Quit smoking tobacco 2 months ago 3. Regularly smoked marijuana as a teenager 4. Sustained a concussion a month ago

4. Sustained a concussion a month ago Rationale A concussion can result in traumatic brain injury (TBI). Recent TBI is the strongest predictor of PTSD. A family history of depression is a risk factor for possible depression that can be diagnosed in some cases of PTSD but it is not a strong predictor of the disorder. The remaining options are not relevant to the diagnosis of PTSD.

Which interventions are associated with primary crisis care? Select all that apply. 1. Discussing impact of crisis on the client 2. Administering antidepressant medication as prescribed 3. Planning for discharge, beginning with the admission interview 4. Assisting the client with learning new problem-solving techniques 5. Helping the client to identify environmental changes necessary to reduce stress

1. Discussing impact of crisis on the client 4. Assisting the client with learning new problem-solving techniques 5. Helping the client to identify environmental changes necessary to reduce stress Rationale Primary care promotes mental health and reduces mental illness to decrease the incidence of crisis. On this level the nurse can work with a client to recognize potential problems by evaluating the client's experience of stressful like events; teaching the client specific coping skills, such as decision making, problem solving, assertiveness skills, meditation, and relaxation skills; and assisting the client in evaluating the timing or reduction of like changes to decrease the negative effects of stress as much as possible. This may involve working with a client to plan environmental changes, to make important interpersonal decisions, and to rethink changes in occupational roles. Administering antidepressant medication and planning for discharge are examples of secondary care.

Which coping mechanism is commonly adopted during a crisis? 1. Engaging in other physical activity 2. Setting realistic goals 3. Avoiding talking with others 4. Avoiding eating

1. Engaging in other physical activity Rationale During a crisis, clients use different coping techniques to cope with the situation. Some clients may get involved in physical activity such as walking to relieve restlessness. Because the client has had a crisis, the client may not be psychologically stable and might not be able to set realistic goals. Some clients may try to cope with the stress by talking to others. Some clients tend to overeat in order to cope with stress.

A nurse is assessing an adult client with posttraumatic stress disorder (PTSD)? Which symptom should the nurse expect to find? 1. Mood alterations 2. Undisturbed sleep 3. Talking about memories 4. Unchanged concentration levels

1. Mood alterations Rationale Posttraumatic stress disorder usually follows a traumatic or stressful event and is characterized by reexperiencing, avoidance, hypervigilance, and alterations in mood. Mood alterations like chronic depression are a feature of posttraumatic stress disorder. Clients with PTSD have difficulty sleeping or are troubled by dreams of past events. Clients with PTSD often avoid talking about memories related to the past traumatic event and may have difficulty concentrating.

A nurse is caring for a client diagnosed with schizophrenia. Which type of intervention should the nurse plan to ensure the safety of the client? 1. Primary intervention 2. Tertiary intervention 3. Secondary intervention 4. Critical incident stress debriefing

3. Secondary intervention Rationale Secondary intervention includes coping strategies from acute crisis and prolonged anxiety levels. The prime theme of secondary intervention is to ensure the safety of the client. It includes the assessment systems, support systems, and coping strategies. Primary interventions include psychotherapeutic crisis interventions. Tertiary interventions include coping for clients with a disabling mental state. Critical incident stress debriefing is a form of tertiary intervention.

A nurse is caring for an adult client who has been diagnosed with a trauma-related disorder. The client reports to the nurse that he has started using relaxation techniques and is sleeping better. As what should the nurse interpret this? 1. The client is feeling uneasy. 2. The client is feeling less confident. 3. The client is able to manage anxiety. 4. The client has improved self-esteem.

3. The client is able to manage anxiety. Rationale Using relaxation techniques shows that the client is able to manage anxiety, which enables the client to sleep better. A client who is uneasy may not sleep properly or use relaxation methods. Using relaxation techniques and having adequate sleep may make the client more confident. Positive behaviors like maintaining eye contact and positive talk about self-indicate improvement in the client's self-esteem.

Two 16-years-olds were involved in a car accident in which another friend was killed have engaged in counseling after the accident. While one of the teens has been able to move forward with little dysfunction, the other is experiencing anxiety and an inability to concentrate in school even after numerous counseling sessions. What is the most likely reason to account for the difference in the way individuals who experience the same event are affected emotionally by that event? 1. Perception of the event 2. Individual personality 3. Previous trauma 4. The type of counseling provided

1. Perception of the event Rationale People vary in the way they absorb, process, and use information from the environment. Some people may respond to a minor event as if it were like-threatening. Conversely, others may experience a major event and look at it in a calmer fashion. Individual personality, previous trauma, and the type of counseling provided may be true, but are not the primary reasons two people respond differently to the same event

The expected outcome at the conclusion of crisis intervention therapy is that the client will function 1. At a higher level than before the crisis. 2. At the pre-crisis level. 3. Only marginally below the pre-crisis level. 4. Without aid from identified support systems.

2. At the pre-crisis level. Rationale The intent of crisis intervention is to return the individual to the pre-crisis level of functioning. A crisis would not provide the necessary teaching factors to result in the functioning at a higher level. The goal is not to lose function. Not all crises require help from a support system.

In the United States, which agency has overall responsibility to coordinate responses to disasters? 1. World Health Organization (WHO) 2. Department of Homeland Security (DHS) 3. Federal Emergency Management Agency (FEMA) 4. National Incident Management System (NIMS)

2. Department of Homeland Security (DHS) Rationale The DHS has ultimate government responsibility for the safety of United States citizens and territories while assuring adequate preparedness, response, and recovery protocols are immediately available. WHO serves the global community. DHS oversees operations of FEMA. NIMS helps first responders from different disciplines and areas to work together effectively when a community has exhausted its available resources in addressing a large-scale occurrence.

A couple is planning a large wedding in a city 100 miles from their home. When the couple tells the nurse this information, which response does the nurse expect to be associated with this experience? 1. Distress 2. Eustress 3. Acute stress 4. Depersonalization

2. Eustress Rationale This situation would likely provoke eustress, or positive, beneficial stress. Distress is negative stress that causes emotional and physical problems. Acute stress occurs after a violent or traumatic event. Depersonalization, associated with posttraumatic stress disorder, is a feeling of being detached from one's mental processes or body.

When a client complains of being "stressed out," the nurse understands that this label may include what experiences? Select all that apply. 1. Sleeping through the night 2. Excessive appetite 3. Loss of interest in favorite activities 4. Headaches and back pain 5. Difficulty concentrating

2. Excessive appetite 3. Loss of interest in favorite activities 4. Headaches and back pain 5. Difficulty concentrating Rationale Feeling "stressed out" is commonly associated with changes in appetite, loss of interest in favorite activities, headaches and back pain, difficulty concentrating, and difficulty sleeping.

Which outcome indicates that the individual is demonstrating a commonly observed but negative coping strategy after a crisis event? 1. Scheduling spiritual counseling sessions three times a week 2. Gaining 10 lbs over a 6-week period of time 3. Losing one's driver's license for driving drunk 4. Offering numerous excuses for not socializing 5. Running 5 miles daily

2. Gaining 10 lbs over a 6-week period of time Rationale Common coping mechanisms may be overeating, drinking, smoking, withdrawing, yelling or fighting. Counseling and reasonable exercise would not be considered negative coping strategies.

Following an assessment, the nurse concludes that the client is in phase 2 crisis. What signs and symptoms support this conclusion? 1. Suicidal intentions 2. Intention to harm others 3. Feelings of extreme discomfort 4. Severe panic

3. Feelings of extreme discomfort Rationale Crisis is categorized into Your distinct phases based on the behavior of the client. A client in phase 2 crisis has feelings of extreme discomfort, threat, and anxiety. Patients in phase 4 have suicidal ideation and/or intention to harm others. Patients who exhibit severe panic and withdrawal are included in phase 3.

A client with posttraumatic stress disorder (PTSD) is finishing outpatient therapy. What behavior most clearly suggests the client is recovering? 1. Living alone 2. Regularly attending church 3. Having breakfast with a friend weekly 4. Sleeping restlessly at night

3. Having breakfast with a friend weekly Rationale Having breakfast with a friend weekly is a clear positive outcome of therapy after PTSD. Living alone does not support the client building social connections. Attending church may support the client recovering but is not as supportive as regular visits with a friend. Clients should sleep restfully to support overall health and well- being. Sleeping restlessly is a symptom of PTSD.

A client who survived a bomb blast has symptoms of chronic depression, irritation, and insomnia. Which statement of the nurse is appropriate to be included in the client teaching regarding management guidelines? Select all that apply. 1. "Don't consume alcohol." 2. "Coffee should be avoided." 3. "Keep practicing deep breathing and aerobic exercises." 4. "Dreaming about the traumatic event is a normal response to your trauma." 5. "Smoking will cause your symptoms to worsen."

1. "Don't consume alcohol." 2. "Coffee should be avoided." 3. "Keep practicing deep breathing and aerobic exercises." 4. "Dreaming about the traumatic event is a normal response to your trauma." Rationale A client who has been rescued from a bomb blast has experienced trauma. Symptoms of trauma include chronic depression, irritability, and insomnia. During trauma, the client has reduced attention, so the client must avoid consumption of alcohol. Alcohol reduces the client's ability to pay attention and causes impaired memory and motor coordination. The client with trauma may have insomnia. Therefore, coffee must be avoided, because it is a stimulant and may worsen sleep difficulties. The client must be encouraged to do deep breathing and aerobic exercise for relaxation. Dreaming about the traumatic event is a normal response to illness. Although smoking is to be avoided for general health reasons, nicotine is not known to have a negative effect on the conditions being experienced by this client.

When discussing the symptoms of posttraumatic stress disorder (PTSD), which statement by the nurse is correct? 1. "The symptoms can occur almost immediately or can take years to manifest." 2. "PTSD causes agitation and hypervigilance, but rarely chronic depression." 3. "When experiencing a flashback, the client generally experiences a slowing of responses." 4. "PTSD is an emotional response that does not cause significant changes in brain chemistry."

1. "The symptoms can occur almost immediately or can take years to manifest." Rationale The onset of PTSD symptoms can occur as early as a month after exposure, but a delay of months or years is not uncommon. PTSD can cause agitation, hypervigilance, and chronic depression. Flashbacks are not associated with a slowing of responses. PTSD is associated with significant changes in brain chemistry.

Which factor can adversely affect a person's ability to respond positively to a crisis situation? Select all that apply. 1. A lack of supportive services 2. The actual nature of the crisis 3. An unrealistic perception of the crisis 4. Reliance on ineffective coping mechanisms 5. The age of the individual at the time of the crisis

1. A lack of supportive services 3. An unrealistic perception of the crisis 4. Reliance on ineffective coping mechanisms Rationale A person's equilibrium may be affected adversely by one or more of the following: an unrealistic perception of the precipitating event, inadequate situational supports, and inadequate coping mechanisms. Age and nature of the crisis are not considered as impactful.

When an individual in the second stage of crisis is unable to resolve the situation by using his or her usual coping strategies, the individual is likely to implement which coping strategy? 1. Becomes disorganized and uses trial-and-error problem solving. 2. Withdraws and acts as though the problem does not exist. 3. Develops severe personality disorganization. 4. Resorts to planning suicide.

1. Becomes disorganized and uses trial-and-error problem solving. Rationale Becoming disorganized and using trial-and-error problem solving is characteristic of the second stage of crisis, according to accepted crisis theory. Withdrawing and acting as though the problem does not exist, developing severe personality disorganization, and planning suicide are not associated with the second stage of crisis.

The nurse manager instructed the nurse to conduct crisis intervention for a client whose parents died in an accident. How should the nurse start the crisis intervention for the client? 1. By establishing rapport with the client 2. By understanding the feelings of the client 3. By planning interventions for the client 4. By teaching mindfulness to the client

1. By establishing rapport with the client Rationale According to Robert's seven-stage model of crisis intervention, developing a relationship with the client is the initial step in managing a crisis. The nurse should establish rapport with the client to develop trust and a healthy relationship. Once the client is comfortable with the nurse, the client will be able to express feelings freely with the nurse. The nurse can understand the client's feelings after the client starts interacting with the nurse. Based on the assessments of the problems and coping skills of the client, the nurse can plan the intervention to help the client cope with stress. Once the planning of the interventions is done, the nurse can implement the teaching of various coping strategies such as mindfulness to the client.

What is the priority concern for the crisis intervention nurse? 1. Client safety 2. Setting up future contacts 3. Brainstorming possible solutions 4. Working through termination issues

1. Client safety Rationale Client safety is always the priority concern in crisis intervention therapy. The disequilibrium of crisis predisposes the client to suicidal thinking. Setting up contacts, brainstorming solutions, and working through termination issues are all concerns of crisis intervention, but they are secondary to safety.

A client with a diagnosis of obesity has been participating in a new program of exercise for 60 minutes a day, five times a week to facilitate a weight loss. What type of stress is the client experiencing? 1. Eustress 2. Distress 3. Stress response 4. Chronic stress

1. Eustress Rationale Eustress is beneficial stress; it motivates people to develop the skills they need to solve problems and meet personal goals. Distress causes problems both emotionally and physically. Stress response is also referred to as flight or fight response that is a survival mechanism by which our body and mind become immediately ready to meet a threat or stress. Chronic stress is a long-term stress that can cause physiological harm and increased chronic emotional difficulties.

Which are the most likely causes of stress? Select all that apply. 1. Low social status 2. Threats to self-esteem 3. Loud noises 4. Defense mechanisms 5. Poverty

1. Low social status 2. Threats to self-esteem 3. Loud noises 5. Poverty Rationale Low social status, threats to self-esteem, loud noises, and poverty are likely causes of stress. Defense mechanisms may be used in an attempt to relieve stress.

Three weeks after being assaulted by a client, a nurse develops headaches, insomnia, and gastrointestinal problems that result in four absences from work over a 2-week period. Which action should the nursing supervisor employ? 1. Refer the nurse for counseling and support. 2. Ask the nurse about current personal problems. 3. Direct the nurse to take paid vacation for the following week. 4. Schedule the nurse for administrative tasks rather than client care.

1. Refer the nurse for counseling and support. Rationale The supervisor should refer the nurse for counseling and support so that the nurse can address the event and ensuing symptoms. Asking the nurse about his or her personal problems is not the correct action, because it does not address the crisis the nurse is experiencing in the aftermath of the assault. Directing the nurse to take paid vacation does not address the nurse's apparent needs and is the incorrect action. Scheduling the nurse for administrative tasks rather than client care does not aid the nurse in addressing the event and resulting symptoms, so this is the incorrect action.

A nurse on a busy medical-surgical unit is complaining of fatigue. What is the most likely cause of fatigue in a nurse who is otherwise healthy? 1. Secondary stress trauma 2. Acute stress disorder 3. Posttraumatic stress disorder 4. Traumatic brain injury

1. Secondary stress trauma Rationale Secondary stress trauma, also known as compassion fatigue, is a cumulative physical, emotional, and psychological stress. Acute stress disorder, posttraumatic stress disorder, and traumatic brain injury are all related to a specific event causing damage or physiological stress.

Which statements are true regarding tertiary crisis care? Select all that apply. 1. The care may be provided on an outpatient basis. 2. A goal is to have the client regain optimum function. 3. A goal is the prevention of further crisis-related emotional disruption. 4. Sheltered workshops are not designed to provide tertiary crisis care. 5. Care focuses on recovery from a disabling mental state resulting from a crisis.

1. The care may be provided on an outpatient basis. 2. A goal is to have the client regain optimum function. 3. A goal is the prevention of further crisis-related emotional disruption. 5. Care focuses on recovery from a disabling mental state resulting from a crisis. Rationale Tertiary care provides support for those who have experienced a severe crisis and are now recovering from a disabling mental state. Social and community facilities that offer tertiary intervention include rehabilitation centers, sheltered workshops, day hospitals, and outpatient clinics. Primary goals are to facilitate optimal levels of functioning and prevent further emotional disruptions.

. . Which situation has the potential for early crisis intervention to occur? 1. The client tells the nurse in the well-baby clinic that she's feeling uptight and has arranged to see a primary care therapist. 2. The client is hospitalized after an unsuccessful suicide attempt that she states, "was a mistake." 3. The client asks for reassurance that he will be welcome at the day hospital after his hospital discharge. 4. The client enters the emergency department with a strong smell of alcohol on his person, stating he is anxious and depressed.

1. The client tells the nurse in the well-baby clinic that she's feeling uptight and has arranged to see a primary care therapist. Rationale Phase I intervention is when a person confronted by a conflict or problem that threatens the self-concept responds with increased feelings of anxiety. The increase in anxiety stimulates the use of problem-solving techniques and defense mechanisms in an effort to solve the problem and lower anxiety. An unsuccessful suicide attempt deemed a mistake indicates a phase 4 response to a crisis; reassurance would be a phase 3 response. The inebriated client is using inappropriate coping mechanisms that are not effective to treat depression and anxiety.

The nurse assessing a client who survived a terrorist attack finds that the client is demonstrating impaired thinking and severe anxiety. Which strategy should the nurse implement while conducting crisis intervention for the client? Select all that apply. 1. The nurse focuses on the present situation of the client. 2. The nurse assures the client that he or she will be fine within 2 days. 3. The nurse encourages the client to express feelings in a nondestructive manner. 4. The nurse encourages the client to focus on multiple implications at a time. 5. The nurse assists the client to identify past coping skills.

1. The nurse focuses on the present situation of the client. 3. The nurse encourages the client to express feelings in a nondestructive manner. 5. The nurse assists the client to identify past coping skills. Rationale While conducting the crisis intervention, the nurse should focus on the present situation of the client. It helps to plan an effective treatment plan. The nurse should encourage the client to express feelings in a nondestructive manner. It helps to ensure safety of others and the client. The nurse should assist the client to identify past coping skills. It helps the client to develop problem-solving and decision-making skills. The nurse should not give false assurance that the client will be fine within 2 days. It usually takes 4 to 6 weeks for the client to recover from a crisis. The nurse should encourage the client to focus on one implication at a time to avoid stress and confusion.

A college student has been experiencing significant stress associated with academic demands. Last month, the student began attending yoga sessions three times a week. Which outcome indicates to the nurse that this activity has been successful? 1. The student reports improved feelings of well-being. 2. The student increases use of caffeine to enhance concentration. 3. The student reports, "Now I am sleeping about 10 hours every day." 4. The student says, "I withdrew from two courses to reduce my academic load."

1. The student reports improved feelings of well-being. Rationale Yoga and other physical activities can be effective ways to manage stress. These activities deepen breathing, relieve muscle tension, and can elevate levels of the body's own endorphins, which induces a sense of well- being. Lowering caffeine intake is associated with lower stress, and chronically stressed people are often fatigued and therefore oversleep. Increasing caffeine use does not indicate a positive outcome. On its own, sleeping 10 hours a day does not necessarily indicate a positive outcome. Withdrawing from courses is not an indication that yoga has lowered the student's stress level; it is a different approach entirely.

A 12-year-old female finds herself feeling anxious and overwhelmed and seeks out the school nurse to report that "Everything is changing; my body, the way the boys who were my friends are treating me, everything is so different." It is likely the child is describing what disorder? Select all that apply 1. Personal identity disorder 2. A maturational crisis 3. Suicidal ideations 4. Mild neurosis

2. A maturational crisis Rationale The maturational crisis of moving from childhood into adolescence may be difficult because many new coping skills are necessary. The child's description does not indicate a personal identity disorder, suicidal ideation, or neurosis.

Which scenario describes a client in phase IV of a crisis response? 1. Individual experiences increased anxiety and feelings of extreme discomfort the day after a tornado. 2. Individual comes to the crisis clinic complaining of depression and expresses that he or she does not want to go on living. 3. Individual experiences a panic attack at his or her mother's home in a nearby town where the client is staying after a tornado. 4. Individual experiences anxiety symptoms the day after he or she was fired.

2. Individual comes to the crisis clinic complaining of depression and expresses that he or she does not want to go on living. Rationale The individual coming to the crisis clinic complaining of depression and expressing that he or she does not want to go on living describes phase IV, when, if coping is ineffective, may lead to depression, confusion, violence, or suicide. The other options describe phase II (extreme distress), phase III (panic attack), and phase I (anxiety) in phases of crisis.

What statement accurately describes a maturational crisis? Select all that apply. 1. Such crises occur once adulthood has been reached. 2. Physical changes may result in conflict or crisis. 3. This form of crisis represents both vulnerability and potential. 4. New coping skills must be learned because old ones are ineffective. 5. Retirement can result in a maturational crisis for some individuals.

2. Physical changes may result in conflict or crisis. 3. This form of crisis represents both vulnerability and potential. 4. New coping skills must be learned because old ones are ineffective. 5. Retirement can result in a maturational crisis for some individuals. Rationale Maturational crises are associated with maturation, a process that occurs across the life cycle. Each maturational stage represents a time where physical, cognitive, instinctual, and sexual changes prompt an internal conflict or crisis, which results in either psychosocial growth or regression that represents increased vulnerability, and at the same time, heightened potential. When a person arrives at a new stage, formerly used coping styles are no longer effective, and new coping mechanisms have yet to be developed and must be learned. Examples of events that can precipitate a maturational crisis include leaving home during late adolescence, marriage, birth of a child, retirement, and the death of a parent. One does not need to be an adult to experience a maturational crisis.

A client reports feeling his or her heart racing when experiencing stress. What system is responsible for this sensation? 1. Central nervous system 2. Sympathetic nervous system 3. Parasympathetic nervous system 4. Limbic system

2. Sympathetic nervous system Rationale When activated by a stressor, the sympathetic nervous system increases the heart rate, a physical response to stress. The central nervous system involves the brain and spinal cord. The limbic system controls emotional responses. The parasympathetic nervous system promotes relaxation.

What is the defining characteristic of acute stress disorder that distinguishes it from posttraumatic stress disorder (PTSD)? 1. Occurs after a traumatic event 2. Symptoms resolve within 1 month 3. Sleep is restless with nightmares 4. Irritability caused by basic work and family issues

2. Symptoms resolve within 1 month Rationale The defining difference between acute stress disorder and PTSD is that symptoms of acute stress disorder resolve within 1 month. A traumatic event, restless sleep, and irritabilities are common to both conditions

The nurse must initially assess a client in crisis for which equilibrium-focused behavior? 1. Self-report of feeling depressed 2. Unrealistic report of a crisis-precipitating event 3. Report of a high level of anxiety 4. Admission that he or she is abusing drugs

2. Unrealistic report of a crisis-precipitating event Rationale A person's equilibrium may be affected adversely by one or more of the following: an unrealistic perception of the precipitating event, inadequate situational supports, and inadequate coping mechanisms. These factors must be assessed when a crisis situation is evaluated because data gained from the assessment are used as guides for both the nurse and the client to set realistic and meaningful goals, as well as to plan possible solutions to the problem situation. Feelings of depression or anxiety and admission of drug use are important to the crisis management process, but they are secondary to assessing the client's report of the event.

A client's spouse was killed during a robbery 10 days ago. The client, who has a long history of mental illness, cries spontaneously when talking to the nurse about the loss. What is the nurse's most therapeutic response? 1. "This loss is harder to accept because you have mental illness. Try to focus on other activities." 2. "I'm concerned that you are crying so much. Your grief over your spouse's death has gone on too long." 3. "The sudden death of your spouse is hard to accept. I am glad you are able to tell me about how you are feeling." 4. "Your tears let me know you are not coping appropriately with your loss. Let's make an appointment with your health care provider."

3. "The sudden death of your spouse is hard to accept. I am glad you are able to tell me about how you are feeling." Rationale Through sharing his or her experience, the client can begin to heal and integrate what happened into his or her life. The nurse demonstrates caring and compassion by using therapeutic communication techniques to acknowledge that the death is hard to accept and encouraging the client to talk about his or her feelings. The loss would be hard for anyone to accept, regardless of mental illness. Crying and other symptoms of grief after only 10 days are expected and are not an indication of inappropriate coping.

The nurse is conducting crisis intervention for a client in a flood-affected area. What appropriate actions should the nurse take? Select all that apply. 1. Ask the client to describe previous problems. 2. Anticipate that the client would be less receptive than usual. 3. Encourage the client to set realistic goals. 4. Focus on the present problems of the client. 5. Assume that the client has a chronic psychiatric disorder.

3. Encourage the client to set realistic goals. 4. Focus on the present problems of the client. Rationale The nurse should plan a focused intervention and encourage the client to set realistic goals. Having a focused intervention helps to effectively manage the client's problems. Setting realistic goals helps the client to achieve them, preventing the frustration and disappointment that occur when goals are not met. The nurse should deal only with the present problems of the client to resolve the immediate crisis and return the client to at least a pre-crisis level of functioning. The nurse should not focus on the previous problems of the client because they may not be relevant. A client in crisis need not have a chronic psychiatric disorder. The nurse should assume that the client is mentally healthy and is onIy in a state of disequilibrium due to the present situation.

A parent seeks counseling after the rape and murder of a child. The parent tearfully says, "I hate the person who did this. At the trial, I don't know what I will do if he's not found guilty." What is the nurse's highest priority response? 1. "Do you have enough support from your family and friends?" 2. "What resources do you need to help you cope with this situation?" 3. "Have you talked to a psychiatrist about taking some medication to help you cope?" 4. "Are you thinking of killing yourself or the person you believe killed your child?"

4. "Are you thinking of killing yourself or the person you believe killed your child?" Rationale Safety is the nurse's highest priority. The nurse should clarify and assess the client's intentions and then initiate necessary precautions to safeguard the client or others at risk for physical harm. Asking about support, resources for coping, or medication represent later actions the nurse may consider.

While conducting an initial interview, the client, a war veteran, shares with the nurse that "Sometimes I still hear explosions, but I know I am safe in my home." What is the nurse's best response? 1. "Your description indicates flashbacks, which are commonly associated with acute stress disorder. You need to have additional treatment." 2. "Exposure to intermittent explosive devices often damages a person's ears. Let's arrange for some tests of your hearing and balance." 3. "Your experience in the war is over and you are safe. It is time for you to recognize that experience is over and you should move on with your like." 4. "You are describing flashbacks. These often happen after traumatic events such as war. I'd like to arrange for you to talk more about your feelings and reactions."

4. "You are describing flashbacks. These often happen after traumatic events such as war. I'd like to arrange for you to talk more about your feelings and reactions." Rationale This veteran is describing flashbacks, a major feature of posttraumatic stress disorder (PTSD). Flashbacks are dissociative experiences during which the event is relived, and the person behaves as though he or she is experiencing the event at that time. Additional evaluation and treatment are indicated. The symptoms this client describes do not suggest acute stress disorder. Although hearing may be damaged, treatment of PTSD has a higher priority. Reactions to traumatic events may occur years after the experience.

A community is experiencing a high degree of illness after a devastating earthquake. What percentage of diseases are related to stress? 1. 60% 2. 70% 3. 80% 4. 90%

4. 90% Rationale It is believed that as many as 90% of diseases are stress-related. A higher percentage than 60%, 70%, or 80% are related to stress. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a Your-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.

Which is an example of a maturational crisis2 1. Experiencing an unplanned pregnancy. 2. Losing one's job within months of retiring. 3. Working at a bank that recently was robbed. 4. Having one's only child leave home to attend college.

4. Having one's only child leave home to attend college. Rationale Maturational crises are related to traditional periods of like where roles are changing, such as experiencing midlife empty nesting. An unplanned pregnancy can result in a situational crisis if the individual's equilibrium is upset enough. The loss of a job at any time can result in a situational crisis. Being victimized, such as in a robbery, can result in a situational crisis if the individual's equilibrium is upset enough.

Which event can lead to the development of a situational crisis in clients? 1. Physical assault 2. Natural disaster 3. Birth of a child 4. Loss of a job

4. Loss of a job Rationale A situational crisis arises from external events such as loss of a job or an abortion. An adventitious crisis results from accidental events that are unplanned, which may be human-made or caused by nature. This crisis arises from situations such as physical assaults and natural disasters like floods and earthquakes. A maturational crisis arises from developmental changes in a person's life such as the birth of a child or death of parents.

A client is experiencing stress at work. What is an example of a physical stressor in the workplace? 1. Staff cliques 2. Guilt 3. Low pay 4. Loud noises

4. Loud noises Rationale Loud noises are an example of a physical stressor in the workplace. Staff cliques and low pay are psychosocial stressors. Guilt is a psychological stressor.

During which crisis phase does a client exhibit serious personality disorganization, depression, and confusion? 1. Phase 1 2. Phase 2 3. Phase 3 4. Phase 4

4. Phase 4 Rationale Caplan was the first person who conducted an extensive study on individual behavior. He proposed Your stages based on the emotional status of a client during a crisis. Patients with high personality disorganization, depression, and confusion are categorized under phase 4. These clients also exhibit suicidal thoughts. Increased level of anxiety caused by external stimuli is experienced by a client during phase 1. lithe anxiety level grows to a level of extreme discomfort, the client has reached the phase 2 level of crisis. Phase 3 is characterized by an increased level of panic due to grief and loss.

A nurse conducting crisis intervention for a client has identified that the client demonstrates impaired social interaction. Which symptom supports this conclusion? 1. The client is overwhelmed. 2. The client has exaggerated startle response. 3. The client avoids using social support. 4. The client has difficulty with interpersonal relationships.

4. The client has difficulty with interpersonal relationships. Rationale An assessment of the signs and symptoms of stress in a client in crisis is the initial step for formulating an effective crisis management plan. lithe client has difficulty with interpersonal relationships, then the nursing diagnosis for the client would be impaired social interaction. lithe client is in an overwhelmed state, then the diagnosis of the client would be disturbed personal identity. Startle response is a symptom of anxiety, and decreased use of social support would come under the diagnosis of ineffective coping.

An elderly client suffered from a head injury after a fall several months ago. During a transfer to the chair, the client suddenly becomes alert and combative. What does the nurse identify as the most likely cause of this behavior? 1. The client is concerned with the nurse's ability to transfer safely. 2. The client has a sleep disturbance causing irritability. 3. The client was socially withdrawn and now has recovered. 4. The client is recalling the original trauma from falling.

4. The client is recalling the original trauma from falling. Rationale The most likely cause of the client's behavior is the client recalling the original trauma from falling. Exposure to stimuli similar to that which caused a traumatic injury can cause an exacerbation of the trauma. The information provided does not suggest the client questions the nurse's ability, has a sleep disturbance, or is recovering from being socially withdrawn.