trauma and crisis

Which question best assesses an individual's ability to cope with the potential emotional crisis resulting from the death of a parent?

"Have you ever lost a loved one before?

The nurse is assessing a patient's support systems. Which question would most help the nurse identify support systems?

"Have you ever used a community agency for support?"

The nurse provides care for a patient with posttraumatic stress disorder (PTSD) related to a sexual assault. Which statement made by the patient makes the nurse suspect the patient is experiencing dissociation?

"I feel like everything in my life is a dream."

The nurse is providing discharge teaching to a patient who was recently raped. What should the nurse say regarding the psychological effects of the assault?

"It is normal to experience depression after being sexually assaulted.

A nurse is caring for a patient who was sexually assaulted at a party. The nurse teaches cognitive coping skills to the patient. Which response by the patient indicates effective teaching by the nurse?

"It is now my turn to support my parents and take care of them."

A nurse prepares to implement a critical incident stress debriefing for first responders to a plane crash. The nurse must correctly organize the elements of the debriefing for maximum effectiveness. Put the elements in the order they should occur after an explanation of the purpose and ground rules of the meeting are established.

4Ask participants to describe their own symptoms experienced at the scene as well as after the initial experience 5Acknowledge and affirm the normality of expressed symptoms; offer anticipatory guidance

Which government entity is charged with coordinating responses to American disasters, particularly in situations in which local and state resources are inadequate to the presenting challenge?

Department of Homeland Security (DHS

In the United States, which agency has overall responsibility to coordinate responses to disasters?

Department of Homeland Security (DHS)

Which statement indicates that a victim of a sexual assault is showing signs of recovery? Select all that apply.

I'm getting 6 to 8 hours of uninterrupted sleep most nights "My parents and friends have been very supportive through it all. I'm looking forward to going back to school right after spring break.

What is the primary factor that makes an event a crisis?

Ineffectiveness of one's usual coping strategies

Which statement reflects a truth about rape?

Most rapes are planned

Which situation has the potential for early crisis intervention to occur?

Mrs. R tells the nurse in the well-baby clinic that she's feeling uptight and has arranged to see a primary care therapist

A patient is treated in the emergency department for injuries sustained while vacationing hundreds of miles away from home. To best meet the patient's emotional needs, the nurse should do which of the following?

Provide temporary support by arranging shelter and contacting the patient's friends

A female patient is raped by her husband frequently. What psychological effect would the nurse observe in this patient?

Sexual distress

Which response illustrates the best practice in giving care to a patient who has just been sexually assaulted?

Supportive: "I am going to stay with you. We can talk as long as you want to.

In the legal system, what is a patient of sexual assault known as?

Victim

When does a patient have symptoms of self-hatred and depression?

When the patient has chronic low self-esteem

Care planning for the rape victim is facilitated if the nurse understands that rape trauma syndrome is actually a variant of which of the following?

post-traumatic stress disorder

It has been 6 months since a patient who was raped began counseling. Which statement by the patient would indicate that an important outcome has been met?

"I am not going to let that rapist be in control of my life. I know things will keep getting bette

The nurse is caring for a patient who was raped about a year ago and was diagnosed with acute stress disorder. Which statement made by the patient indicates signs of recovery? Select all that apply.

"I'm sleeping about six straight hours each night." "My best friend takes me out for coffee twice a week. "I really enjoy cooking and having dinner parties with my friends.

After a major hurricane destroys a community, which statement best indicates that an individual is likely to maintain or promptly return to a state of equilibrium?

"I've been through big storms before. If we pull together, we can help each other and rebuild our community.

Three weeks after a patient was raped she tells the nurse, "I am going crazy. I have nightmares and wake up screaming. Then during the day all sorts of thoughts about the rape intrude into whatever I am concentrating on. I can't get anything done at work." How should the nurse reply?

"These are normal responses to stress and will decrease with time and therapy.

A major hurricane destroyed a community. Afterward, which comment best predicts that a victim will be able to maintain or promptly return to a state of equilibrium?

"We had had big storms before. If we pull together, we can help each other and rebuild our community.

The nurse is assessing a patient with rape-trauma syndrome. The patient killed the perpetrator in an attempt to save herself. The patient tells the nurse, "I am a murderer. I killed that man. I should have tried to run away. Why did I have to kill the man?" What should be the response given by the nurse to the patient?

"You have done the correct thing to save your life.

Behaviors have been identified for the various phases of crisis. Place the provided options in the order they are likely to be demonstrated.

1Feeling of anxiety 2Disorganizational thinking 3Fight or flight response occurs 4Demonstration of suicidal behaviors

A crisis is so acutely uncomfortable to the individual that it is likely to self-resolve in what time frame?

4 to 6 weeks

Which are foundational theory concepts for crisis intervention? Select all that apply.

A crisis intervention deals only with the patient's present problem A crisis is self-limiting and usually resolves within four to six weeks Early intervention probably increases the chances for a good prognosis

Which best describes the principle of crisis intervention?

A directive, time-limited, and goal-directed strategy designed to assist individuals who are experiencing crisis

In the event of an adventitious crisis, which age group would be least in need of crisis intervention?

A distinction cannot be made

Which factor can affect adversely a person's ability to respond positively to a crisis situation? Select all that apply

A lack of supportive services An unrealistic perception of the crisis Reliance on ineffective coping mechanisms

Which statement is true regarding the nursing care of a forensic patient? Select all that apply.e

A victim of a sexual assault meets the criteria of a forensic patient Asking about possible suicidal ideations may be an appropriate interview question Sexual assault nurse examiners (SANE) are trained especially to meet the needs of a sexual assault victim

A rape victim experiences intrusive dreams, flashbacks, and recurring images of the incident since it occurred 3 weeks ago. What is the possible nursing diagnosis of the rape victim?

Acute stress disorder

Which statement concerning a crisis is true? Select all that apply.

Adaptation to the results of the crisis is vital to recovery. A crisis involves a struggle to regain one's emotional equilibrium.

A victim of date rape is hospitalized with agitation, bradycardia, and hypothermia. Laboratory reports reveal G-hydroxybutyric acid (GHB) in the patient's blood. Which nursing intervention helps manage bradycardia?

Administering atropine to the patient

A family's home and possessions are lost when a massive forest fire burns out of control. What type of crisis has occurred?

Adventitious

When a tornado results in the loss of homes, businesses, and life, the town residents are likely to experience what type of crisis?

Adventitious crisis

The nurse is preparing to assess a patient who is in the emergency room accompanied by friends. The friends report that the patient may have been "roofied." What does the nurse immediately assess to check for symptoms of an overdose?

Airway

Whose model does a nurse follow while conducting crisis intervention for a patient with acute stress disorder?

Albert R. Roberts

A patient who was raped one year ago talks with the nurse. Which comment by the patient indicates a successful resolution of this traumatic event?

Although I have a nightmare once in a while, most of the time I sleep soundly."

A victim of rape is diagnosed with rape-trauma syndrome. Which signs and symptoms does the nurse find in the victim? Select all that apply.

Anxiety Aggression Nightmares

Statistics about sexual violence in the United States:

Are unreliable because rape is underreported

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?

Are you thinking of killing yourself or others like the person who killed your child?

What measures should the nurse take while assessing a rape victim? Select all that apply.

Ask questions using descriptive terms Ask questions in a nonjudgmental tone Ask the patient to talk at a comfortable pace

The nurse assesses a patient who was raped. Which component of the assessment has priority?

Ask the patient about suicidal tendencies directly

The nurse is caring for a depressed patient who was rescued from an earthquake. As part of the counseling and treatment, the nurse wants to assess the patient's family and the patient's stressors. What appropriate action will the nurse take?

Ask the patient to describe his or her feelings

An adolescent brings a friend to the emergency department. The adolescent says to the triage nurse, "My friend was raped. Somebody gave her some Special K." The friend is confused, dazed, and drooling. What is the nurse's priority action?

Assess the friend's airway and breathing pattern

The nurse is performing crisis intervention for a patient who has been sexually assaulted. What appropriate action does the nurse take first?

Assess the patient for any suicidal intentions

Which nursing intervention is most appropriate during the follow-up visit of a rape survivor after discharge from the hospital?

Assessing for pregnancy

The expected outcome at the conclusion of crisis intervention therapy is that the patient will function in which of the following ways?

At the pre-crisis level

What are the categories of rape? Select all that apply.

Attempted rape Completed rape

When a stressful event occurs and the individual in the second stage of crisis is unable to resolve the situation by using his or her usual coping strategies, the individual

Becomes disorganized and uses trial-and-error problem solving

The nurse manager instructed the nurse to conduct crisis intervention for a patient whose parents died in an accident. How should the nurse start the crisis intervention for the patient?

By establishing rapport with the patient

The goal of crisis intervention has been met when a mother who lost her job does which of the following?

Describes her new job as being better than the old one

Which interventions are associated with primary crisis care? Select all that apply.

Discussing impact of crisis on the patient Assisting the patient with learning new problem solving techniques Helping the patient to identify environmental changes necessary to reduce stress

While caring for a victim of sexual abuse, a nurse finds that the patient is depressed and is having suicidal ideation. Which question does the nurse ask to assess the situational support of the patient?

Do you take part in organized religious services?"

Which nursing action has priority for a patient immediately following a reported rape?

Document the debris and dirt on the patient's clothing

Which principles related to crisis resolution direct the care provided by a crisis intervention nurse? Select all that apply.

Early intervention probably increases the chances for coping that is effective During a crisis, people often are more receptive than usual to outside intervention The goal of crisis intervention is for the patient to regain pre-crisis-level functioning

The nurse is conducting crisis intervention for a patient in a flood-affected area. What appropriate actions should the nurse take? Select all that apply.

Encourage the patient to set realistic goals Focus on the present problems of the patient

What are the indicators of sexual abuse recovery in a patient? Select all that apply.

Expressions of hope Feelings of empowerment Healing of physical injuries Evidence of comfort in relationships

Following an assessment, the nurse concludes that the patient is in phase 2 crisis. What signs and symptoms does the nurse find in the patient?

Feelings of extreme discomfort

The nurse assesses a victim of incest who is receiving psychiatric therapy. Which finding could indicate that the patient may be experiencing avoidance?

Feelings of guilt

A nurse is teaching a group of nursing students about sexual assault. Which information should the nurse include in the teaching?

Fifty percent of all rapes occur in the home

A nurse manager instructs a nurse to perform crisis intervention for an acute crisis. Which step should be the priority while conducting secondary care for the patient?

Focus on the safety of the patient.

According to Caplan, crisis occurs in four phases. Which patient behavior is an example of phase 3 of a crisis?

Following the death of a spouse, the patient progresses from mild anxiety to a panic state. The patient tells the nurse, "I cannot live alone! I will need to move in with my children."

A nurse is performing a clinical examination of a patient who was sexually abused. The nurse finds that the patient has reduced blood pressure, hypothermia, and respiratory depression. Which "date rape" drug would the nurse expect to find in the patient's blood sample report?

G-hydroxybutyric acid

Which outcome indicates the individual is demonstrating a commonly observed but negative coping strategy after a crisis event? Select all that apply.

Gaining 10 pounds over a 6-week period Losing one's driver's license for driving drunk Offering numerous excuses for not socializing

Which is a common drug that is illegally used for victims of date rape and also used to treat narcolepsy?

Gamma-hydroxybutyric acid (GHB

In the emergency department, a rape victim is examined and evidence is collected. How will this care be reimbursed?

Government or tribal resources pay for the care

The nurse is performing crisis intervention for a sexually assaulted patient. What appropriate action should the nurse take to help the patient cope with the crisis? Select all that apply.

Guide the patient about maintaining support systems Encourage the patient to express feelings in a nondestructive manner Frequently restate the statements made by the patient during interview

The nurse is caring for a patient in the emergency room who was in a serious motor vehicle accident in which a child died. Which assessment question takes priority?

Have you thought about hurting yourself

Which of the following is an example of a maturational crisis?

Having one's only child leave home to attend college

What are the signs and symptoms of rape-trauma syndrome? Select all that apply.

Hypervigilance Feeling numb Intrusive thoughts

The nurse meets with a patient who was a victim of sexual assault. Which statements made by the patient indicate recovery? Select all that apply.

I feel comfortable hanging out with my male friends.

A student nurse interacts with the sexual assault nurse examiner (SANE) during internship. The student nurse asks the SANE to share an experience while caring for victims of sexual assault. Which response given by the SANE is appropriate?

I have seen rape victims from 6 months to 90 years old.

The patient experiences each of the following during his or her crisis. Which scenario describes a patient in phase 4 of a crisis response?

Individual comes to the crisis clinic complaining of depression and expresses that he or she does not want to go on living

The nurse interacts with a patient at a crisis center. The patient speaks of distressing events and makes dismissive comments. What diagnosis should the nurse make from the patient's symptoms?

Ineffective denial

Which of the following would be an appropriate long-term outcome for a rape victim?

Integrate the rape event and resume an optimal level of functioning

Anticipatory teaching of a rape victim should include information that a common survivor problem that often develops with acute stress disorder is

Intrusive thoughts

What is the action of an emergency contraceptive pill?

It inhibits the process of ovulation

The nurse is providing community teaching to a group of adolescents about ways to prevent rape. Which statement made by the adolescent indicates further teaching must occur?

It isn't rape if the participants are in a relationship

A rape victim has been admitted in the hospital. On acquiring the history from the law enforcement officials, the nurse finds that the patient was drugged before rape. During the examination, the nurse finds that the patient is in a dreamlike state and is not responding to painful stimuli. Which drug should the nurse suspect to have been used to drug the patient?

Ketamine

Which drug associated with date rape has the shortest duration?

Ketamine

The nurse prepares to perform a general assessment on a patient who was sexually assaulted. What does the nurse include in the assessment? Select all that apply.

Level of anxiety Coping mechanisms Available support systems

When the patient begins to sob uncontrollably and speech becomes so incoherent that the patient is unable to give the nurse any information, the immediate interventions will focus on which of the following?

Lowering the patient's anxiety level from severe to moderate

A man is having difficulty adjusting to becoming a father. He has not bonded with his newborn and frequently stays out at night drinking with friends. Which type of crisis is evident?

Maturational

What is the term for crises that occur as an individual moves from one developmental level to another?

Maturational crises

Three weeks after being raped by an adult male, a petite college female says to the nurse, "My roommate says the rape was my fault. She says I could have gotten away if I had tried." What information will the nurse consider when responding to this comment? Select all that apply.

Most men can overpower most women because of differences in body build Victims of rape often panic, resulting in decisions and actions that are ineffective.

A nurse is performing an assessment of a patient who was sexually assaulted. The patient reports being unconscious 10 minutes after having a cool drink. The nurse anticipates that the patient was given flunitrazepam with the drink. Which symptom does the nurse find in the patient?

Muscle relaxation

Which statement accurately describes the epidemiology of rape?

Nearly half of female victims have been raped by an acquaintance

Which statement is currently true regarding the existence of sexual assault in the United States? Select all that apply.

Nearly one in five women has been raped within her lifetime Nearly a third of male victims were raped by intimate partners. The male is likely to have been victimized by several assailant The first rape experience in female victims happens before the age of 25 the majority of the time

Which sample must be collected as legal evidence for sexual assault? Select all that apply.

Oral swabs Blood sample Vaginal swabs

What interventions should be included during a rape examination? Select all that apply

Palpating for signs of invisible injury Recording injuries in written and photographic form conducting a superficial genital examination and speculum exam

What is the priority concern of the crisis intervention nurse?

Patient safety

What are the two initial goals for crisis interventions?

Patient safety and anxiety reduction

Which criteria are considered when planning relevant outcomes for patients in crisis? Select all that apply.

Patient-centered focus Outcomes are culturally sensitive Family has input when appropriate Patient's personal values are considered

Which of the following is the best description of completed rape?

Penetration without the consent of the victim

Mason and Charlie, both 16 years old, were involved in a bad car accident in which they were both passengers. Mason spoke with a counselor about the incident once and has been able to move forward with little dysfunction. Charlie has been experiencing anxiety and an inability to concentrate in school even after numerous counseling sessions. What is the most likely reason that accounts for the difference in the way individuals who experience the same event are affected emotionally by that event?

Perception of the event

During which crisis phase does a patient exhibit serious personality disorganization, depression, and confusion?

Phase 4

What is the best description of a psychiatric advance directive plan?

Proactive method of addressing a crisis situation before it occurs

A crisis intervention nurse knows that crisis victims need assistance with many aspects of getting through the crisis. What is the highest priority of care for such patients?

Promoting patient safety

What is the role of the advanced practice nurse in the management of a rape victim?

Provide individual psychotherapy

The nurse is assessing a patient with anxiety who is a victim of intimate partner abuse. Which nursing intervention will help in reducing the anxiety levels of the patient?

Provide knowledge of problem-solving techniques

The nurse cares for a 42-year-old woman who was raped the preceding night. The woman is considering morning-after medication to avoid pregnancy resulting from the rape. The nurse does not believe in abortion. Which action by the nurse is most appropriate?

Provide the woman with information about morning-after medication

A rape victim is discharged home after initial treatment. Which method of giving follow-up instructions is most appropriate?

Provide written instructions

Which nursing intervention helps reduce severe anxiety in a patient who has been physically abused?

Providing compassionate support for the patient

The nurse is teaching a group of adolescents about sexual violence. During the discussion, an adolescent states, "My parents tell me to avoid going out with my friends. They ask me to come home directly after school. When I ask the reason, they say that they fear that someone would hurt me." According to the adolescent's statement, what is the myth related to rape that the adolescent's parents believe?

Rapes usually occur in dark alleys

After the bomb explosions at the Boston Marathon in 2013, members of the community donned t-shirts that said, "Boston Strong." Which phase of the disaster management continuum is evident by this behavior?

Recovery

A sexual assault victim asks to be given "the morning-after pill" to prevent conception. The nurse does not believe in abortion. What action should the nurse take?

Report and document the request

In which phase of a disaster management program does the healthcare professional implement the actual disaster plan?

Response

The nurse is explaining the forensic exam to a patient who was just sexually assaulted. The patient does not want to be examined and says, "I feel like my body just keeps getting violated more and more." Which is the best term used to describe this feeling?

Revictimization

The nurse is caring for a patient who recently escaped a relationship marked by repeated domestic violence. The nurse observes that the patient is unable to make decisions and is dependent on the nurse. What appropriate action should the nurse take?

Set realistic goals for the patient

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." What is likely about this child?

She is experiencing a maturational crisis

An adult has a family history of colon cancer, so this adult has screening colonoscopies every 5 years. At age 55, the colonoscopy reveals a malignant tumor in the ascending colon. The nurse should assess this adult for which type of crisis?

Situational

Which type of crisis arises from events that are extraordinary, external rather than internal, and often unanticipated?

Situational

When the nurse finishes addressing a group of college women about rape, the following comments are heard during the discussion period. Which comment calls for additional teaching by the nurse?

So if you dress conservatively, your risk of being raped is small.

To provide discharge treatment and support, the nurse should realize that the most common sequelae of acquaintance rape is the development of which of the following?

Symptoms of sexual distress

The nurse is performing crisis intervention for a patient rescued from a bomb blast. What appropriate actions should the nurse take while working with the patient? Select all that apply

Teach decision-making skills to the patient Consider that a crisis counseling relationship is one between partners

Which stage of critical incident stress debriefing includes acknowledgement of expressed symptoms?

Teaching phase

The nurse observes as a student nurse assists with the discharge of a patient who was raped. Which actions made by the student nurse cause the nurse to intervene? Select all that apply.

Telling the patient to call the hospital in a few days to receive a list of support groups in the community Verbally telling the patient about legal matters, online resources, and potential physical concerns that the patient will experience

The nurse is counseling a patient at a crisis center. After assessing the patient's situation, the nurse identifies that the patient is suffering from adventitious crisis. Which patient response supports the nurse's findings?

Terrorists brutally killed all the passengers; I somehow managed to escape.

After a disaster, a nurse leads a discussion designed to assist rescuers to talk about their feelings and reactions as well as to support their coping skills. What level of crisis intervention is represented by this action?

Tertiary

The student nurse is providing examples of adventitious crisis to a peer. Which examples of adventitious crisis listed by the student nurse requires correction? Select all that apply.

The birth of a child Death of a loved one A change in financial status Leaving home for the first time

On the way home from work a nurse comes upon a severe automobile accident. The driver emerges from the car without apparent physical injuries but is unable to recall the spouse's phone number, has difficulty finding a driver's license, and has diaphoresis and trembling. How will the nurse assess this reaction?

The driver is experiencing disequilibrium.

A nurse is teaching a group of nursing students about emergency nursing interventions for sexual assault victims. Which statement made by the student indicates effective learning? Select all that apply.

The emergency nurse should identify and assess the victims of sexual assault. A sexual assault nurse examiner is part of a multidisciplinary team in the hospital. A specially trained advocate may be present while assessing the victim of sexual assault.

Which assumption serves as a foundation for the use of crisis intervention?

The individual is mentally healthy but in a state of disequilibrium

A nurse is performing the clinical assessment of a patient who was sexually abused during a date. What appropriate actions does the nurse take during assessment?

The nurse assesses the usefulness of the patient's social support system.

A nurse is assessing emotional trauma in a patient who was sexually assaulted. What action does the nurse take while performing the assessment? Select all that apply.

The nurse encourages the patient to talk at a comfortable pace The nurse asks the patient, "Are you having any suicidal intentions?"

A nurse is performing a physical examination of a female patient who was sexually abused. Which steps does the nurse follow while performing the assessment? Select all that apply.

The nurse explains the examination procedure to the patient The nurse inquires about the date of the patient's last menstrual cycle The nurse encourages the patient to participate in all the decisions of the assessment

The nurse is assessing a patient with bipolar mood disorder. The patient cries out loudly and tells the nurse, "My husband is hurting me. Please save me from him." After assessing the patient, the nurse tells the patient, "I believe you. I am here to help you." What is the reason for the nurse's response?

The nurse finds physical signs indicating sexual assault.

The nurse is assessing a patient rescued from a terrorist attack and finds that the patient has impaired thinking and severe anxiety. Which strategy does the nurse use while conducting crisis intervention for the patient? Select all that apply.

The nurse focuses on the present situation of the patient The nurse assists the patient to identify past coping skills The nurse encourages the patient to express feelings in a nondestructive manner

A patient comes to the crisis intervention clinic and tearfully tells the nurse, "It is so painful! I have thought about it, and I cannot see how I can go on without my partner." The nurse states, "You have resilience and will look back on this as a crisis you were able to manage." Analysis of this interaction reveals what about the nurse?

The nurse has not followed up on the patient's verbal clues to suicidal thoughts

A patient who was sexually assaulted was treated effectively and discharged. What appropriate action should the nurse follow while discharging the patient?

The nurse should give printed follow-up instructions to the patient

A nurse is conducting crisis intervention for a patient who is a victim of physical assault and learns that the patient is confused and overwhelmed. Which strategy does the nurse implement while interacting with the patient to make the patient feel comfortable?

The nurse summarizes the information given by the patient

A nurse is planning crisis intervention for a patient who has acute stress and panic episodes. Which nursing intervention does the nurse implement while giving primary care to the patient?

The nurse teaches relaxation techniques to the patient.

The nurse is caring for a patient with rape-trauma syndrome. What outcome shown by the patient after 8 weeks indicates effective crisis intervention?

The patient concentrates on the given task

A nurse caring for a patient who was sexually assaulted reports to the primary healthcare provider that the patient has effectively recovered. Which responses by the patient led the nurse to identify the patient's effective recovery? Select all that apply.

The patient expresses the right to be protected The patient starts interacting with family members The patient expresses anger in a nondestructive way

After long-term treatment, the nurse is evaluating a patient who was sexually assaulted. The nurse reports to the primary healthcare provider that the patient has recovered. Based on which action of the patient does the nurse give the report? Select all that apply

The patient finishes meals The patient has reduced vaginal discharge

A nurse is conducting crisis intervention for a patient, and has identified that the patient has impaired social interaction. Which sign and symptom does the nurse find in the patient?

The patient has difficulty with interpersonal relationships

The nurse is caring for a patient with acute stress disorder who is also a rape victim. The patient wakes up suddenly from sleep and cries out loudly. This takes place about 2-3 times every night. What should the nurse document in the patient's case file?

The patient has frequent re-experiences of the assault.

A nurse is caring for a patient who was sexually assaulted. The nurse reports to the primary healthcare provider that the patient has arousal symptoms. Which symptom is the nurse referring to in the patient?

The patient has insomnia and reduced concentration

An individual comes to the crisis clinic for a first visit and reports not sleeping well, anxiety, and excessive crying. These symptoms occurred shortly after a sudden job loss and losing his or her home to a tornado that devastated the town in which the patient lives. Which of the following statements regarding crisis accurately describes the individual's situation?

The patient is experiencing both a situational and an adventitious crisis

A nurse is caring for a group of patients in a rehabilitation center who were rescued from a tornado. The nurse identifies a patient with disturbed identity who is isolated from the other patients. What does the nurse interpret from the patient's behavior?

The patient is in a depressed state

An adult recently diagnosed with multiple sclerosis says, "I'm worried I won't be able to support my family or send my children to college." This person begins drinking alcohol heavily and omitting prescribed medications. What is the likely cause of the patient's behavior?

The patient is in a state of situational crisis.

Which assessment finding would the nurse expect in a patient who needs further treatment for post-traumatic stress disorder (PTSD)?

The patient is restless

A nurse is conducting crisis intervention for a patient in a rehabilitation center with extreme levels of depression. The patient has low self-esteem and impaired social interaction. Which outcome in the patient indicates effective crisis intervention?

The patient starts setting goals

A nurse is preparing the care plan of a patient who has rape-trauma syndrome. What should the nurse include as an outcome measure for this patient in the care plan?

The patient will be able to control impulses

A victim of rape who is unconscious has been admitted to the hospital. The blood tests revealed that the patient has consumed a high dose of gamma-hydroxybutyric acid (GHB). What should the nurse anticipate in this situation? Select all that apply.

The patient will undergo endotracheal intubation The patient will be given a benzodiazepine injection

The nurse is assessing an adolescent patient who has been raped by a stranger. What question should the nurse ask the patient to assess the likelihood of pregnancy?

What is the date of your last menstrual period?"

To assess the patient's perception of the event precipitating a crisis, the nurse would initially ask which of the following questions?

What was happening just before you began feeling this way?"

A woman comes to the crisis intervention clinic expressing concern that her 16-year-old is using illegal drugs in their home. What action will the nurse take?

Work with the patient to set goals that are mutually acceptable.

During the immediate post-rape period what verbal nursing intervention would best lower patient anxiety and increase feelings of safety?

You are safe here. I will stay with you while you have your examination.