Chapter 23: Crisis and Disaster

12. A woman expecting to pick her husband up at the airport has instead just been told that he has been killed in an airplane crash. Crisis counselors are present to help loved ones cope with the sad and sudden news. Which response by the counselor would be most appropriate to make next? a. State, "I will stay with you," and allow for a period of silence so she can process the news of her loss. b. Ask, "What would help you in this difficult time? Would you like to speak with a chaplain?" c. Ask, "Is there is someone who's supportive, who can take you home and spend time with you over the next few days?" d. State, "We realize this is very sudden and unexpected and very upsetting. The airline is committed to helping you in this difficult time."

ANS: A Persons facing traumatic news can experience a form of psychological shock wherein information processing can be significantly impaired. Indicating an intent to stay with the patient conveys support, helps establish a therapeutic relationship, and ensures that the patient is safe. (In some cases, survivors become suicidal at the prospect of being without their loved one or wish to rejoin their loved one in death.) Observing a period of silence allows the patient to process the news and begin to develop her initial responses. The patient needs this time to process events before facing other questions or being provided with instructions or information (which will be difficult for the patient to remember under the circumstances). Offering a chaplain could be perceived as disinterest in remaining with the patient—a form of rejection—and although connecting the woman with support resources appropriate to her particular religious and cultural preferences would be helpful later, it is premature at this very early stage of adjustment. Indicating that the airline desires to be helpful, when the airline is responsible for the crash and resulting deaths, could be perceived as self-serving and draw a very angry, nontherapeutic response from the survivors.

9. A nurse in the emergency room is responsible for responding to crises involving school children and has spent many days in local schools helping grieving students who have lost peers or teachers unexpectedly. She is also exposed daily to the victims of horrible accidents and other physical and emotional traumas. Which of the following would be most important for her to address in periodic clinical supervision? a. Vicarious traumatization b. Evidence-based interventions c. Research on crisis response d. Physiological response to crises

ANS: A Persons who work with survivors of trauma are indirectly—vicariously—exposed to trauma themselves and can experience the same sort of responses as those who experience trauma directly, especially as their exposure to such second-hand trauma accumulates. This phenomenon is called vicarious traumatization, and a nurse working repeatedly with traumatized students would be at risk. An emergency room nurse also experiences trauma directly in the process of caring for those who have been injured by traumatic events. Critical incident stress debriefing (CISD) is helpful and indicated for crisis counselors and others at risk for vicarious traumatization, just as it is for emergency responders at risk for posttraumatic stress disorder. Although all of the topics listed would be appropriate for discussion during supervision, focusing on the prevention of vicarious traumatization would be most important because it is essential to preserving the nurse's physical and psychological well-being.

24. A factory abruptly closes during hard economic times. An office worker initially tries to take it in stride, begins the job search, and networks with peers. Six weeks later, he has not received a single call-back from a prospective employer. He cannot sleep, is irritable, does not want to interact with his family or peers, paces frequently, and spends several hours most days alone in a local bar. Bills are piling up. He has given up applying for jobs. Which short-term indicator would be most important at this time? a. Patient sleeps at least 6 hours per night. b. Patient no longer goes to bars each day. c. Patient no longer paces regularly. d. Patient considering jobs to apply for.

ANS: A Resumption of normal sleep patterns suggests that depression is improving, and the increased rest should enable him to begin to cope more effectively. Reductions in pacing and going to the bar may either be a positive indicator or mean that the individual has become more immobilized. Considering jobs to apply for indicates he is moving toward more adaptive coping but not necessarily that he is making effective coping efforts.

14. The priority assessment the nurse must make during the initial crisis intervention interview is the: a. need for external controls. b. adequacy of social supports. c. patient's perception of the precipitating event. d. patient's preferred coping mechanism.

ANS: A Safety needs of patients and others are of high priority, so assessment of potential for harm to self or others is of greater importance than the other options.

22. A factory abruptly closes; workers receive no warning and no explanation. An office worker tries to take it in stride and begins the job search, updating his resume, submitting applications, and offering support to his peers. Which assessment question would be most important to ask at this time? a. "Tell me how has this affected you, how things seem to you." b. "What do you think you will do if your plan does not work?" c. "Tell me about some other difficult times you've been through." d. "Tell me who cares about you, supports you, who you can count on."

ANS: A The initial focus in crisis situations should be on determining how the patient sees the event and his current situation and, in particular, whether psychiatric treatment or admission is needed to provide for his safety or prevent decompensation. A broad opening question that yields information on how the person interprets the event and how it has affected him so far helps to determine his perception of events and whether he requires psychiatric care. Seeking information about past crisis responses, present coping efforts, and future plans would follow.

18. A patient, aged 16 years, comes to the crisis clinic and tells the nurse that an uncle tried to rape her yesterday. The patient had told her mother of the uncle's behavior, but the mother accused the daughter of lying and, contrary to the patient's hopes, indicated she would still allow the uncle to visit the family. The patient describes feeling "all confused" and shows minor lacerations on her forearms to the nurse, which she indicates she did out of desperation rather than a wish to die. Which nursing diagnosis would be most appropriate as her primary diagnosis? a. Powerlessness b. Disturbed thought processes c. Rape-trauma syndrome d. Interrupted family process

ANS: A The patient, a teenager, has relatively little control over her circumstances compared to her parents. However, when she approached her parent seeking support and protection, she was instead rebuffed and identified as the perpetrator rather than the victim. The patient made an effort to exert the power available to her by reporting the attempted assault, only to be accused herself and have the protection she desired withheld. Of the diagnoses listed, the most applicable would be powerlessness. There are no data to support an alteration in thought processes or interruption in family process. Rape-trauma syndrome involves posttraumatic stress disorder-like symptoms that include flashbacks and intrusive thoughts, none of which are documented here.

4. A patient presents in crisis. She tells the nurse, "I cannot take it anymore! It has to stop. Last year my husband had an affair, and we do not communicate anymore. Three months ago I found a lump in my breast, and yesterday my 20-year-old daughter told me she is quitting college and moving to another state with her boyfriend." The nurse can make the assessment that crisis intervention is successful when the patient: a. resolves her grief regarding the actual and potential losses in her life. b. permits others to make decisions for her until her anxiety is reduced. c. develops a higher degree of resilience to use when facing future crises. d. learns to respond more calmly and logically in crisis situations.

ANS: A When a person's crisis centers on actual or potential losses, the patient is dealing with actual or anticipatory grief. Although the actual or threatened losses increase anxiety as well, successful resolution of the crisis depends on resolving the grief she is experiencing. Permitting others to assume decision making increases dependency and is rarely a strategy in crisis intervention. Enhancing resilience is always desirable but is not required to resolve the present crisis. Learning to respond more calmly when under stress would seem helpful but is not fundamental to resolving a crisis situation.

17. Which health care worker should be referred to critical incident stress debriefing? a. A nurse who worked 8 hours answering visitor queries at the intensive care unit information desk after a bus crash led to multiple admissions b. The emergency medical technician who treated victims of a car bomb attack on a large department store c. A nurse who works at an oncology clinic with patients receiving chemotherapy, many of whom are terminally ill d. A case manager working day in, day out, with low-functioning severely mentally ill persons in group homes

ANS: B 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 emergency medical technician who experienced an adventitious crisis event by responding to a bomb attack and providing care to trauma victims.

8. A patient being interviewed on his first visit to the crisis center says he is there because he needs help, but then he falters and cannot continue his explanation. Which question would be of value in helping him relate his perception of the precipitating event? a. "It will be hard to help you if we cannot get more information." b. "Tell me about what happened that led you to come in today." c. "Who is available to help and support you with your problem?" d. "What things do you usually do to get through difficult times?"

ANS: B Asking the patient to talk about what led him to visit to the clinic will help the patient identify the precipitating event. The precipitating event must be identified before planning, goal setting, and intervention can take place. Pointing out that his reticence interferes with treatment does not address any of the reasons he is having difficulty speaking; instead, it adds to the pressure he is already experiencing. Focusing on supports and coping skills is part of the assessment but does not address the precipitating event.

6. The crisis that occurs as an individual moves from young adulthood to middle age and becomes concerned with loss of his youthful appearance would be assessed by the nurse as a(n) ____ crisis. a. situational b. maturational c. reactive d. adventitious

ANS: B 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.

2. A patient presents in crisis. She tells the nurse, "I cannot take it anymore! It has to stop. Last year my husband had an affair, and we do not communicate anymore. Three months ago I found a lump in my breast, and yesterday my 20-year-old daughter told me she is quitting college and moving to another state with her boyfriend." After making the assessment that the patient's nuclear family is unable to provide the patient with sufficient support, which intervention would be most appropriate? a. Suggest that the patient seek admission to the inpatient crisis stabilization unit. b. Explore other possible sources of support among her extended family and friends. c. Allow her to vent, and explore her concerns about the daughter's plan to leave. d. Foster insight by relating the present situation to earlier situations involving loss.

ANS: B The assessment of supports should continue; even though the patient's nuclear family may not be supportive, other supportive family or peers may be available. An inpatient or crisis center admission would be an option for a patient at risk for self-harm or decompensating emotionally, but typically this would not be sought otherwise, unless outpatient interventions were proving inadequate to stabilizing her. Allowing her to vent, exploring concerns, and building insight are therapeutic responses but are of lower priority than establishing a system of support outside of the counseling relationship.

19. Which of the following indicators best demonstrates that crisis intervention has been successful? a. Patient reports that he is no longer distressed. b. Patient reports that his life is back to normal. c. Patient reports sleeping 6 hours or more per night. d. Patient has returned to previous work schedule.

ANS: B The focus of crisis intervention is on returning the patient to at least his pre-crisis level of functioning, as suggested by "life is back to normal." The other indicators suggest progress but are not as definitive in showing that the main goal of crisis intervention has been achieved.

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

ANS: B The only answer universally true for all patients in crisis is that they are experiencing a period of disequilibrium, when their capacity and resources for coping have been overwhelmed, upsetting the previous balance in their lives. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness, and although some traumatic events may result in risk to self or others, this does not occur in most cases.

21. A factory abruptly closes; workers receive no warning and no explanation. An office worker tells the factory nurse, who is standing by to assist overwhelmed employees: "I do not know what to do. How will I get another job? Who will pay the bills? How will I get money to feed my kids? What will we do?" Which nursing diagnosis best fits this presentation? a. Hopelessness b. Powerlessness c. Chronic low self-esteem d. Disturbed thought processes

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

11. A woman goes to the airport to pick up her husband, returning from one of many business trips. Persons awaiting his flight are directed to a conference room where airline counselors explain that the flight crashed into the ocean, and it is believed that there are no survivors. The woman tells a counselor that it is too soon to be sure, he might still be alive, clinging to wreckage and waiting to be found. The patient is demonstrating: a. trial-and-error problem solving. b. adaptive denial. c. ineffective denial. d. acute confusion.

ANS: B The patient is denying the very likely death of her husband. Denial reduces anxiety, and it is adaptive when it serves to help the patient cope until more adaptive coping strategies and resources can be brought to bear. It would be ineffective denial if it failed to help her anxiety or was not replaced with more effective coping mechanisms. There is no indication that the patient is confused about the circumstances facing her. Trial-and-error problem solving is not in evidence, since it would involve a series of random responses, each tried in turn after the pervious effort failed.

20. A 40-year-old man has just helped his youngest child move away to college. On returning home, he feels empty and restless and has difficulty sleeping in the nights that follow. This is an example of a ______________ crisis. a. situational b. adventitious c. maturational d. midlife

ANS: C A maturational crisis is one that occurs predictably when a person arrives at a new stage in life. An example would be a parent whose children are assuming lives of their own, leaving the parent to transition to a new stage of life wherein the role of parent is deemphasized. A situational crisis is one that is specific to a particular external situation that others may not experience; these often involve losses, such as death of a loved one or loss of a job. An adventitious crisis involves an unpredictable traumatic event such as a natural disaster (tornado), manmade disaster (collapse of a building), or criminal event (mugging).

10. During the initial interview at the crisis center, a patient reveals that his wife asked him for a divorce. He is so anxious that he "cannot think straight." Which response would best assess the patient's coping skills? a. "I can see you are upset. You can rely on us to help you feel better." b. "What would you like us to do to help you feel more relaxed?" c. "In the past, how did you handle difficult or stressful situations?" d. "Do you think you deserve to have things like this happen to you?"

ANS: C Exploring past responses to stressful events is the only option that assesses coping skills. Acknowledging distress is helpful, but assuming responsibility for the patient's feeling better is not therapeutic; neither assesses coping ability. Persons in crisis have difficulty with problem solving, so it would be unrealistic to ask them to provide instructions on how staff should help. Asking whether he deserves such experiences would provide information about self-esteem but not coping.

23. A factory abruptly closes. An office worker tries to take it in stride and begins the job search. Three weeks later, he has not received a single call-back from a prospective employer despite submitting over 30 applications. He is having trouble sleeping, is irritable, does not want to interact with his family, paces, and spends several hours most days in a local bar. He is now applying for minimum-wage service jobs. Which phase of the crisis is he experiencing? a. Phase 1 b. Phase 2 c. Phase 3 d. Phase 4

ANS: C In phase 1, the person is anxious but beginning to make efforts to cope based on his usual coping style. In phase 2, the usual coping responses have fallen short, and anxiety continues to rise; functioning deteriorates, and coping efforts become disorganized or random. In phase 3, the random, disorganized attempts at coping have been ineffective, and anxiety has risen to severe or panic levels. Further efforts to cope are maladaptive, and the person may begin to redefine the crisis or compromise in resolving it. If the crisis does not resolve, the person enters phase 4, develops further maladaptive responses, becomes overtly depressed, and can act out violently towards others or himself. This person is in phase 3.

3. A patient presents in crisis. She tells the nurse, "I cannot take it anymore! It has to stop. Last year my husband had an affair, and we do not communicate anymore. Three months ago I found a lump in my breast, and yesterday my 20-year-old daughter told me she is quitting college and moving to another state with her boyfriend." The problem that should be the focus for crisis intervention is: a. the possible cancer and mastectomy. b. the impact of her husband's infidelity. c. coping with her daughter's leaving. d. the disordered family communication.

ANS: C The focus of crisis intervention is on the most recent problem, "the straw that broke the camel's back." The patient had coped with the breast lesion, the husband's infidelity, and the disordered communication. Disequilibrium occurred only with the introduction of the daughter leaving college and moving.

25. A factory abruptly closes during hard economic times. Six weeks later, an office worker has not received a single call-back from a prospective employer. He cannot sleep, is irritable, does not want to interact with his family or peers, paces frequently, and spends several hours most days alone in a local bar. Bills are piling up. He has given up applying for jobs. Which nursing intervention would be most important at this time? a. Explore his feelings supportively and guide him to focus on one concern at a time. b. Discuss ways to improve mood and reduce anxiety, such as exercise and interaction. c. Help him apply for financial assistance such as food stamps and utility reductions. d. Work with patient and family to assure that any guns have been removed from the home.

ANS: D All of these interventions would be appropriate, but given his risk to self secondary to depression, hopelessness, ineffective coping, and isolation, safety is the highest priority. Persons in phase 4 of a crisis can also become violent towards others. Removing weapons from the home removes a common, lethal means of harming others.

15. An appropriate question for the nurse to ask to assess support systems is: a. "Has anything upsetting occurred in the last few days?" b. "What led you to seek help at this time?" c. "How does this problem affect your life?" d. "Who can be helpful to you during this time?"

ANS: D Asking who can be helpful at this time focuses on who can serve as a source of support to the patient. The other options focus on the patient's perception of the precipitating event.

16. The nursing diagnosis of Powerlessness related to impaired problem solving has been established for a patient seeking crisis counseling. An appropriate outcome for this nursing diagnosis would be that the patient will: a. agree to sign a no-suicide contract within 30 minutes. b. resume meeting pre-crisis role expectations within 36 hours. c. state he feels less anxious within 4 hours of the interview. d. describe two possible solutions during the first interview.

ANS: D Determining possible solutions to the problem is the only outcome that addresses the etiology statement of the nursing diagnosis. The diagnosis does not suggest a risk for self-directed violence, and it would be unrealistic to expect such a quick return to previous functioning in a crisis situation. Reducing anxiety is unrelated to the specified nursing diagnosis.

1. A patient, aged 42 years, seeks crisis intervention. She tells the nurse, "I cannot take it anymore! It has to stop. Last year my husband had an affair, and we do not communicate anymore. Three months ago I found a lump in my breast that the doctor is watching closely, and yesterday my 20-year-old daughter told me she is quitting college and moving to another state with her boyfriend." Which comment or concern should be the priority for further assessment? a. What support persons and coping skills the woman has to draw upon b. The status of the marriage and whether the husband is involved in the affair c. How the patient feels about the possibility of having a mastectomy d. What the patient has in mind when she says she "cannot take it anymore"

ANS: D During crisis intervention, the priority concern is patient safety, so it is most important to assess whether the patient is a risk of self-harm (or other-directed violence). Assessing coping skills and resources, assessing her response to the possible breast cancer and her daughter's plans, and the current status of her marriage would all be assessed subsequent to establishing her safety.

5. A patient who sought help in a crisis agrees after the first interview to return to the clinic for daily sessions. The nurse offers many suggestions for lifestyle changes the patient should make as crisis intervention progresses and provides after-hours phone support as well. After several sessions, which response on the nurse's part should most alert the nurse to a need for clinical supervision? a. Occasionally thinking about the patient's situation b. Searching for other possible interventions to use c. Feeling empathy for the patient's recent losses d. Wishing that the patient would be less clingy

ANS: D The nurse feels unrealistic responsibility to "cure" the patient's problems and may be motivated by a need to be needed. The daily sessions and after-hours phone contact suggest possible overinvolvement, and the patient's clinginess indicates that dependence has developed. The nurse is developing resentment in response. The nurse has failed to maintain appropriate professional boundaries, is experiencing countertransference, and should seek supervision to help her regain her objectivity and resolve the dependency in a therapeutic manner. Occasionally thinking about a patient's situation outside of sessions is neither unusual nor indicative of a need for supervision. Searching for additional interventions is not a red flag for supervision unless one is doing so in a manner that is very disproportionate to that exhibited in caring for other patients. Empathy is a therapeutic response and does not merit supervision (though sympathy might).

7. The nurse is asked by the spouse of a patient seeking crisis intervention to give an example of an adventitious crisis. The nurse should mention: a. the death of a child from sudden infant death syndrome. b. being fired from one's job because of company downsizing. c. the retirement of a 64-year-old man after 30 years' service. d. a riot at a rock concert that results in multiple casualties.

ANS: D The rock concert riot is unplanned, violent, traumatizing, and not a part of everyday life. The death of a child and being fired are examples of situational crises. Retirement is an example of a maturational crisis.