Crisis (Pearson)
A patient calls the crisis line asking for help because of "losing everything" after a disaster. Which question should the nurse make a priority? A. "Can you tell me about the event that you experienced?" B. "Are you in a safe place?" C. "Do you feel able to care for yourself?" D. "Do you have access to food?"
"B. Are you in a safe place?" Rationale: The priority is to assess for the patient's safety. The remaining questions can be addressed after the patient's safety has been established. Additional Learning: Crisis Connection steps include: Make contact and connect with the individual. Assess immediate safety needs. Determine thought processes. Scan for physical distress. Listen intently, supporting emotional reactions. Explore perceptions of the crisis. Identify coping strengths. Develop a support plan and a follow-up plan.
A patient taking a benzodiazepine for anxiety asks when the reasons causing the anxiety will be forgotten. Which response should the nurse make to this patient? A. "The medication will not cause you to forget the reasons for the anxiety." B. "It takes a while for the reasons for the anxiety to be eliminated." C. "It's possible that you need a higher dose of the medication." D. "The medication will need be to changed."
A. "The medication will not cause you to forget the reasons for the anxiety." Rationale: Benzodiazepines are intended to reduce anxiety and do not have an amnesic effect. Amnesia will not occur regardless of the length of time the medication is taken. The patient does not need a higher dose or the medication changed as long as the result is a reduction in anxiety. Additional Learning: Medications used during a crisis include: Short-term benzodiazepine therapy. Prophylactic antibiotics.
After experiencing a traumatic event, a patient expresses feelings of distress. Which should the nurse assess first with this patient? A. Ask the patient to rate the distress using a scale. B. Obtain the patient's vital signs. C. Ask the patient to describe the event. D. Assess for suicidal thoughts.
A. Ask the patient to rate the distress using a scale. Rationale: The priority is to have the patient rate the degree of distress. This allows the nurse to determine the perception of the patient. Vital signs can be assessed in conjunction with the physical assessment. The patient can describe the event after the assessment. There is no immediate indication that the patient is suicidal.
After experiencing a natural disaster, a patient believes the event was punishment from God. Which member of the crisis team should the nurse consult? A. Chaplain B. Grief counselor C. Family therapist D. Healthcare provider
A. Chaplain Rationale: The patient's statement reflects spiritual distress. The nurse should consult the chaplain to address the patient's spiritual distress. A grief counselor, family therapist, and the healthcare provider are members of the crisis team whose role does not directly focus on spiritual distress. Additional Learning: Guidelines for therapeutic communication in a crisis include: Incorporate verbal and nonverbal communication. Maintain eye contact, nod when appropriate, and avoid distractions to signal genuine concern for the patient. Maintain congruence between the verbal and nonverbal messages communicated by the nurse. Paraphrase and repeat the patient's statements to validate the nurse's understanding of the patient and seek clarification. Avoid making statements or comments that invalidate or judge the patient's experience instead of listening to and trying to understand it. When appropriate, silence is an effective communication tool. Periods of silence allow the patient to reflect on thoughts and emotions in order to more effectively express them.
The nurse working at the disaster recovery site is approached by a woman who states, "I was just told my husband was in an accident. What happened to him?" The nurse knows that the patient's husband was seriously injured. Which is the nurse's priority action? A. Escort the woman to a private area to talk. B. Inform her that her husband was seriously injured. C. Tell her that the information is confidential and cannot be released. D. Inform her that someone will contact her.
A. Escort the woman to a private area to talk. Rationale: The nurse's priority action is to escort the woman to a private area. The private area should have a place for the woman to sit down to discuss the information. Discussing the fact that her husband was seriously injured in a public place is inappropriate. In times of crisis, the nurse may be the one responsible for communicating bad news regarding injury or death of loved ones. As in all care settings, the nurse uses therapeutic communication strategies to impart this information and to provide support to family or friends as they process the information. It is not appropriate to withhold information during a time of crisis. Additional Learning: Considerations for communicating painful information include: Greet the individual with warmth and kindness. Inform them that you are present to provide support. Provide privacy. Inquire about what is known, answer questions, provide support. Apprise them of current circumstances. Respond therapeutically to their feelings. Ask them how you can be of assistance. Evaluate coping mechanisms. Incorporate cultural and religious practices. Facilitate communication and provide direction. Focus on the immediate reaction and needs. Provide written resources. Follow up with any new information.
The nurse is using the ABCs of crisis counseling while working with a family affected by a disaster. Which nursing intervention is part of the "C" stage? A. Establishing short- and long-term coping mechanisms B. Establishing therapeutic communication C. Providing validation D. Developing a plan of care
A. Establishing short- and long-term coping mechanisms Rationale: Establishing short-term and long-term coping mechanisms is part of the "C", or cope with the problem. Establishing a therapeutic relationship and developing the plan of care are both part of the "A", or achieve rapport stage. Providing validation (of the problem) is part of the "B", or boil down the problem. Additional Learning: ABCs of crisis counseling include: Achieve rapport: Therapeutic communication is used to develop a relationship and plan of care. Boil down the problem: The problem is identified, validation is provided, and intervention is established. Cope with the problem: Short- and long-term coping mechanisms are established.
A patient who lost everything in a house fire questions the reason to continue living. Which action should the nurse make a priority? A. Obtain a referral for a mental health evaluation. B. Refer the patient to social services. C. Administer antianxiety medication, per order. D. Administer antidepressant medication, per order.
A. Obtain a referral for a mental health evaluation. Rationale: A referral for a mental health evaluation is the priority since the patient's statement reflects suicidal ideation. A social service consult and the administration of an antianxiety or antidepressant medication are not priority actions. Additional Learning: Interventions to reduce risk for injury include: Identify risk factors for injury in the patient's home environment that the patient can control and remove. Monitor the patient's community for ongoing threats and changes that could produce new risk factors. Isolate patients from any potential sources of injury. Assign a patient companion to the patient, move the patient to a location where nursing staff can easily observe them, or use restraints as a last resort, if the patient is in a hospital environment and the patient is a source of risk for injury to self.
The nurse is caring for an adolescent patient experiencing a maturational crisis. The patient states, "If my older sister can get through this, so can I." Which type of self-efficacy is the patient demonstrating? A. Vicarious B. Emotional state C. Mastery D. Social persuasion
A. Vicarious Rationale: Based on the patient's statement, the patient is demonstrating vicarious self-efficacy. Vicarious self-efficacy occurs when a patient observes someone similar succeeding or failing at self-performing a task, and tends to believe that they will perform the same task similarly. The patient's statement is not reflective of the self-efficacy influences of emotional state, mastery experience, or social persuasion. Additional Learning: Etiologies of a crisis include: Physical trauma (including rape, assault, and exposure to violence). Emotional trauma (including psychologic and verbal abuse). Exposure to violence, including in the school or workplace settings. Illness and health-related alterations. Significant loss (including death of a loved one or significant other). Exposure to natural and environmental disasters. Exposure to acts of terrorism. Financial stressors. Legal stressors (including divorce, child custody disputes, and identity theft).
The nurse is caring for a child who is displaced after their home caught fire. The parent states to the nurse, "I am concerned that my child has begun wetting the bed." Which is the most appropriate response by the nurse? A. "Bedwetting often occurs after trauma." B. "I will speak with the healthcare provider regarding this issue." C. "There is no need to worry; the issue will resolve itself." D. "Keep reassuring your child that they are safe and the bedwetting will eventually stop."
B. "I will speak with the healthcare provider regarding this issue." Rationale: Bedwetting is a signal of a poor coping response to the trauma that the child experienced and needs to be addressed. Ignoring the poor coping behavior will not resolve the issue. It is important to reassure the child the they are safe, but the circumstances surrounding the abnormal coping mechanism need to be addressed.
The nurse is discussing the holistic approach to nursing care, specifically about the use of patient prayer and coping. The nurse should identify that which individuals experiencing depression are most likely to use prayer for healing? A. A 19-year-old female college student B. A 60-year-old unmarried woman with a high school education C. A 40-year-old married man D. A 12-year-old girl
B. A 60-year-old unmarried woman with a high school education Rationale: A holistic approach to nursing care acknowledges a connection between not only the mind and body, but also the spirit. It is essential that nurses are aware of the patient's use of prayer as a means of coping with depression and healthcare concerns. The groups most likely to use prayer for depression include women, unmarried individuals, individuals with a high school education, and individuals aged 50 to 64. Additional Learning: Integrative health regarding prayer includes: Prayer may be used as a means of coping with depression as well as other healthcare concerns. Prayer is widely used in the quest for healing.
The nurse is caring for a patient who has experienced a crisis. Which intervention should the nurse incorporate into the plan of care to monitor the patient for self-neglect? A. Contact a community resource to assist the patient in gaining independence. B. Assess the patient's nutritional status. C. Assist the patient in identifying small tasks they can accomplish. D. Provide written instructions related to prescribed treatments.
B. Assess the patient's nutritional status. Rationale: The intervention to monitor the patient for self-neglect is the assessment of the patient's nutritional status. Signs of self-neglect include inadequate nutrition, hydration, and hygiene. Contacting a community resource to assist the patient in gaining independence and identifying small tasks the patient can accomplish are interventions to promote effective coping. Providing written instructions related to prescribed treatments can help decrease confusion that may occur. Additional Learning: Interventions to promote self-care include: Encourage family members to assist the patient in meeting self-care needs. Monitor for signs of self-neglect, such as unwashed hair, or clothing the patient has worn for several days or that is mismatched, inadequate, or inappropriate. Encourage family and friends to help with home responsibilities, such as providing child care or making sure bills are paid to prevent further crisis for the patient. Ensure the patient is eating and hydrating enough at home and has support from family or friends in ensuring proper routines of hydration and nutrition. If needed, recommend community nutrition resources such as Meals on Wheels. Help patients reduce stress associated with returning to work during a time of crisis. Help patients research family leave, vacation, and other work resources that may allow them to be away from work for an extended period of time without losing their jobs. In a hospital setting, encourage patients to follow routines of self-care that are within their control. Also ensure that they are taking in appropriate nutrition and hydration.
The nurse is caring for an American Indian patient who refuses analgesics for pain. Which action by the nurse is the most appropriate? A. Discuss the effects the analgesic will have on the patient. B. Encourage the patient to discuss their approach to pain. C. Inform the patient the medication is a standard treatment. D. Assess the mental status of the patient.
B. Encourage the patient to discuss their approach to pain. Rationale: The most appropriate action is to encourage the patient to discuss their approach to pain. Cultural factors may influence how an individual expresses emotion. In certain cultures, expressions of pain, sorrow, or fear are viewed as signs of weakness. The nurse should be aware of the patient's cultural background and, while maintaining respect for the patient's privacy, gently offer the patient the opportunity to express themselves. Discussing the analgesic effect on the patient's pain or informing the patient that analgesics are standard treatment disregards the cultural beliefs of the patient. There is no indication that an assessment of the patient's mental status is required. Additional Learning: Focus on diversity and culture regarding expression of emotion includes: Being aware that cultural factors affect emotion. Offering the patient the opportunity to discuss their emotions Assessing emotions through the patient's cultural viewpoint.
The nurse is caring for a family that has just experienced the death of their father. Which is the most important nursing intervention? A. Explore perceptions of the loss. B. Establish a therapeutic relationship. C. Identify coping strengths. D. Develop a support plan.
B. Establish a therapeutic relationship. Rationale: Establishing a therapeutic relationship is the most important nursing intervention for a family that has experienced the death of a family member. An established therapeutic relationship precedes the exploration of the loss, identifying coping strategies, and developing a support plan. Additional Learning: Nonpharmacologic interventions for a crisis include: Establishing a therapeutic relationship. Ensuring patient safety from the first moment of contact. Mobilizing support through the significant other, family, relatives, friends, church support groups, healthcare institutions, and organizations such as the American Red Cross. Collaborating with mental health professionals.
The nurse is caring for a patient who has learned that her unborn baby will have Down syndrome. Which nursing intervention should increase the woman's ability to cope with the stressor? A. Assess the patient for depression. B. Provide literature on caring for the child. C. Refer the patient to a social worker. D. Monitor the patient for suicide.
B. Provide literature on caring for the child. Rationale: The nursing intervention that will best help the patient with coping is providing literature on caring for the child. Increasing the knowledge of the patient assists in coping with the diagnosis. Assessing for depression, referring the patient to social services, and monitoring the patient for suicide will not increase the woman's ability to cope with the stressor. Additional Learning: Considerations for patients in crisis who are also pregnant include: Allow the patient to express fears and emotions. Validate emotions and correct misconceptions. Provide information specific to their situation. Work with the social system as needed. Monitor for depression and anxiety. Monitor for physical changes that affect maternal/fetal health. Monitor for unhealthy coping mechanisms.
The nurse is caring for a patient who is exhibiting a fight-or-flight response. Which manifestation should the nurse expect to observe? A. Eye contact B. Tachypnea C. Organized thought processes D. Bradycardia
B. Tachypnea Rationale: The nurse would expect to observe an increased respiratory rate. Patients usually have trouble exhibiting eye contact. Patients in fight-or-flight response are usually disorganized in their thought processes. Patients experiencing the fight-or-flight response would show tachycardia, not bradycardia. Additional Learning: Manifestations of a crisis include: Difficulty problem solving. Disorganized thought processes with difficulty processing information. Disorientation. Vulnerability. Increased tension and helplessness. Fearfulness and sense of being overwhelmed. Intense emotional reactions. Increased sensory input and bombardment. Hypervigilance. Intense physical reactions depicted in the fight-or-flight response. By definition, event usually is time limited and resolves within six weeks.
The nurse is preparing to speak with a family regarding the loss of their father. Which therapeutic statement should the nurse include after communicating the loss? A. "I have notified the chaplain to come speak with you." B. "Would you like to tell me how you are feeling right now?" C. "I am here to assist you during this difficult time." D. "Your father's healthcare provider has been notified."
C. "I am here to assist you during this difficult time." Rationale: Offering assistance to the family after the loss conveys empathy and support. The nurse should ask the family if they would like to speak to a chaplain before making any arrangements. Asking the family to start discussing what they are feeling does not give them time to process the information they have just been given. Informing the family that the healthcare provider has been notified is not a therapeutic statement. Additional Learning: Nonpharmacologic interventions for a crisis include: Establishing a therapeutic relationship. Ensuring patient safety from the first moment of contact. Mobilizing support through the significant other, family, relatives, friends, church support groups, healthcare institutions, and organizations such as the American Red Cross. Collaborating with mental health professionals.
The nurse assessing a family at a disaster relief center observes that the child is verbally unresponsive and is sucking their thumb. Which intervention by the nurse is the most appropriate? A. Ignore the child's behavior. B. Reassure the child that everything will be okay. C. Ask the parents about the observed behavior of the child. D. Refer the child for a mental health assessment.
C. Ask the parents about the observed behavior of the child. Rationale: The most appropriate intervention is to ask the parents about the observed behavior of the child. This allows the nurse the opportunity to collaborate with the parents to establish baseline behaviors that have existed prior to the trauma the child may have experienced. The behavior should not be ignored, because it could be an indication of an abnormal response to stress. Reassuring the child that everything will be okay will not provide a baseline assessment of the child's behavior. An assessment should be thoroughly conducted prior to obtaining a referral. Additional Learning: Information to support a child or adolescent in crisis includes: Work closely with parents to assess and care for children/adolescents after a crisis. Teach parents about poor coping responses to monitor for. Ensure that motional support is provided by family and healthcare workers Encourage parents to spend extra time with the child/adolescent talking with them, monitoring behavior, limiting television viewing of the event, and helping maintain a normal routine. Teach signs and symptoms of depression and suicide risk. Encourage counseling for poor coping. Explore creative ways to respond to the crisis.
The nurse is reviewing the chart of a patient who has a history of physical trauma. Which clinical manifestation should the nurse anticipate observing in the patient? A. Decreased awareness of surroundings B. Muted emotional reactions C. Difficulty problem solving D. Resistance
C. Difficulty problem solving Rationale: A clinical manifestation associated with physical trauma is difficulty problem solving. The person who has experienced physical trauma will not have a decreased awareness of surroundings, but rather be hypervigilant. Emotional reactions will be intense, not muted. Resistance is a stage of the stress cycle, not a reaction to physical trauma. Additional Learning: Perception of self-efficacy includes: Mastery experience. Vicarious experience. Social persuasion. Somatic and emotional states.
The nurse is caring for a patient who states, "I did not handle that crisis very well. I do not know what I was thinking at the time." Which best describes the influence on the patient's self-efficacy? A. Vicarious experience B. Social persuasion C. Emotional state D. Mastery experience
C. Emotional state Rationale: Based on the patient's statement, emotional state influenced the patient's self-efficacy. Emotional states are best described as an individual who is self-critical of their stress response or sense of tension when faced with stressors; in turn, these same individuals may perceive their physical response to stress as rendering them susceptible to failure. The patient's statement does not reflect a vicarious experience, social persuasion, or mastery experience. Additional Learning: A situational crisis, such as a flood, involves an unexpected stressor or circumstance that occurs in the course of daily living.
The nurse is caring for an adolescent patient who expresses suicidal feelings related to confusion about their gender identity. Which type of crisis is the patient experiencing? A. Coping B. Situational C. Maturational D. Biogenic
C. Maturational Rationale: The adolescent who expresses suicidal feelings related to confusion about their gender identity is experiencing a maturational crisis. A maturational crisis occurs as individuals grow and progress through normally expected developmental stages. Teens need to develop a sense of self and personal identity. Coping is not a crisis; it is a dynamic process through which an individual applies cognitive and behavioral measures to handle internal and external demands that the individual perceives as exceeding their available resources. A situational crisis occurs as a result of an unanticipated situation occurring in daily life. Biogenic stressors directly trigger the stress response without any necessary cognitive process on the part of the individual; that is, the individual does not need to recognize the experience or circumstance as being stressful. Additional Learning: Types of crisis include: Situational. Maturational.
A patient with a history of type 1 diabetes mellitus and coronary artery disease receives injuries from a motor vehicle crash. Which question should the nurse make a priority? A. "Do you use an insulin pump?" B. "Are you experiencing difficulty breathing?" C. "Do you have any abdominal discomfort?" D. "Are you having any chest pain?"
D. "Are you having any chest pain?" Rationale: The fight-or-flight response occurs after a trauma. A patient who has a history of type 1 diabetes mellitus and coronary artery disease may be at risk for a myocardial infarction due to the acute stress that results from the fight-or-flight response. Questions about an insulin pump, difficulty breathing, and abdominal discomfort can be asked afterwards. Additional Learning: Components of a physical assessment for the patient in crisis include: Physical complaints. Vital signs. System assessment.
The nurse provides teaching to a patient prescribed a benzodiazepine. Which patient statement indicates that further teaching is needed? A. "I have made a follow-up appointment with my healthcare provider." B. "I will only be on this medication for a short time." C. "This medication will act quickly on my anxiety." D. "I will be able to forget everything that has caused my anxiety."
D. "I will be able to forget everything that has caused my anxiety." Rationale: Benzodiazepines are intended to reduce anxiety and do not have an amnesic effect. The patient should follow up with the healthcare provider. A benzodiazepine is intended for short-term use for anxiety. Benzodiazepines are a fast-acting medication for anxiety. Additional Learning: Medications used during a crisis include: Short-term benzodiazepine therapy. Prophylactic antibiotics.
The nurse working in a disaster relief center learns that a victim lost their vehicle in a flood. Which statement should the nurse make at this time? A. "I know just how you feel." B. "It could have been worse." C. "You can always get another car." D. "I'm sorry this happened to you. Is there someone I can call for you?"
D. "I'm sorry this happened to you. Is there someone I can call for you?" Rationale: The nurse should respond to the patient with empathy and provide an opportunity to gather support for the patient. The statement, "I know just how you feel," is an assumption. Telling the patient, "It could have been worse," or "You can always get another car" expresses judgment and is not empathetic. Additional Learning: Additional actions when caring for patients experiencing a crisis include: Nurses need to be constantly aware of the potential dangers and risk of injury involved in responding to patients in crisis. These threats may come from the environment, particularly if the crisis is a natural disaster or community crisis; threats may also come from other people involved in the crisis, and even from the patients themselves. Nurses must also be careful to ensure that in responding to crises they are aware of the possibility of becoming overwhelmed psychologically, emotionally, or physically themselves, to the point where they are no longer able to monitor effectively for risks to their safety.
The nurse working at the scene of a disaster observes a victim pacing, breathing rapidly, and continuously looking around. Which should the nurse conclude the victim is experiencing at this time? A. Confusion B. Disorientation C. Vulnerability D. Fight-or-flight response
D. Fight-or-flight response Rationale: Based on the nurse's assessment, the patient is experiencing a fight-or-flight response. During the fight-or-flight response, the respiratory rate increases and environmental threats appear heightened. Disorientation is a state of mental confusion. The individual described in this scenario is neither disoriented nor confused. Vulnerability is a state of being exposed to the possibility of a physical or emotional attack. Additional Learning: Manifestations of a crisis include: Difficulty problem solving. Disorganized thought processes with difficulty processing information. Disorientation. Vulnerability. Increased tension and helplessness. Fearfulness and sense of being overwhelmed. Intense emotional reactions. Increased sensory input and bombardment. Hypervigilance. Intense physical reactions depicted in the fight-or-flight response. By definition, event usually is time limited and resolves within six weeks.
A patient feeling distressed is asked to rate the feeling on a scale from 1 to 10, with 1 being no distress and 10 being unbearable distress. Which technique is the nurse using during this assessment? A. Estimation B. Tensiometer C. Inter-rater agreement D. Scaling
D. Scaling Rationale: The use of a numeric scale is considered scaling. Scaling helps assess the order of magnitude of an individual's experience. Estimation, tensiometer, and inter-rater agreement are not tools used for the measurement of a patient's distress level. Additional Learning: Components assessed in a health history include: Safety issues. Access to food and shelter. Feelings of hopelessness or threat to self or others. Risk for harm or violence to self or others. Difficulty eating, resting, sleeping, or with self-care. Psychosocial assessment. Sociocultural factors. Culture and spirituality.
The community nurse learns of a family who has moved into a homeless shelter. Which referral should the nurse make first? A. Clergyperson B. Mental health services C. Primary healthcare provider D. Social services
D. Social services Rationale: A social services referral is the most appropriate since social services are able to assist with housing, employment, and other necessary basic services. There is no indication of spiritual distress, mental health issues, or physical illness. Additional Learning: Interventions for the promotion of effective coping include: Providing information about community resources that may help the patient return to independence after a crisis. Presenting a calm and collected demeanor to the patient and family at all times. Removing the patient and the patient's family from visual reminders of the crisis situation. Encouraging the patient and the patient's family members to drink water and eat small snacks to sustain nutrition and hydration. Encouraging the patient and the patient's family members to participate in self-care activities such as sleeping and bathing. Contacting next of kin for the patient to reduce isolation and provide a support system for the patient. Providing patients and their family members with small, simple tasks that they can perform. Keeping patients informed about their medical status or the medical status of their loved one using therapeutic communication techniques.
The nurse provides interventions to address a patient's anxiety after experiencing a house fire. Which finding should indicate to the nurse that care has been effective? A. The patient remains free from injury or self-harm. B. The patient requests assistance from staff when necessary. C. The patient verbalizes awareness of effective coping strategies. D. The patient reports a reduction in stressful feelings.
D. The patient reports a reduction in stressful feelings. Rationale: A reduction in feelings of stress indicates that interventions have been effective. Remaining free from self-harm, requesting assistance from staff when necessary, and verbalizing awareness of effective coping strategies are not directly related to decreased anxiety. Additional Learning: Expected outcomes for patients experiencing crisis include: The patient has identified and removed risk factors for injury from the environment. The patient reports using community resources and sources of social support such as family and friends. The patient reports feeling less anxiety associated with the crisis. The patient maintains proper hygiene, nutrition, hydration, and other self-care tasks, as evidenced by lack of fatigue, maintenance of appropriate weight, and clean clothes and body. The patient displays effective coping techniques that are appropriate to the situation and expresses a regained sense of control over the crisis. The patient is independently oriented to self, time, and place, and can describe the precipitating event.
