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A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would be expected from the driver immediately after this event? (Select all that apply.)
- A. Difficulty using a cell phone
- B. Long-term memory losses
- C. Fecal incontinence
- D. Rapid speech
- E. Trembling
Correct Answer: A,D,E
Rationale: Immediate responses to a crisis include shock, confusion, difficulty with decision-making, and physical symptoms like trembling and rapid speech. Incontinence and long-term memory loss are not typical immediate responses.
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A woman says, 'I can't take anymore! Last year my husband was diagnosed with cancer. Three months ago, I lost my job. Yesterday my daughter said she's quitting college.' What is the nurse's priority assessment?
- A. Identifying measures useful to help improve the couple's communication
- B. Discussing the patient's feelings about the possibility of having a mastectomy
- C. Determining whether the husband is still engaged in an extramarital affair
- D. Clarifying what the patient means by 'I can't take it anymore!'
Correct Answer: D
Rationale: During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills, focusing on the most immediate stressor causing disequilibrium.
Which scenario is an example of an adventitious crisis?
- A. Death of a child from sudden infant death syndrome
- B. Being fired from a job because of company downsizing
- C. Retirement of a 55 year old
- D. A riot at a rock concert
Correct Answer: D
Rationale: An adventitious crisis is unplanned and violent, like a riot. Other options represent situational or maturational crises.
At the last contracted visit in the crisis intervention clinic, an adult says, 'I've emerged from this a stronger person. You helped me feel like my life is back in balance.' The nurse responds, 'I think it would be worthwhile to have two more sessions to explore why your reactions were so intense.' Which analysis applies?
- A. The patient is experiencing transference.
- B. The patient demonstrates a need for continuing support.
- C. The nurse is having difficulty terminating the relationship.
- D. The nurse is empathizing with the patient's feelings of dependency.
Correct Answer: C
Rationale: The nurse's suggestion to continue sessions beyond the crisis focus indicates difficulty terminating the relationship.
Which health care worker should be referred to critical incident stress debriefing?
- A. Nurse who works at an oncology clinic where patients receive chemotherapy.
- B. Case manager whose patients are seriously mentally ill and are being cared for at home.
- C. Health care employee who worked 8 hours at the information desk of intensive care unit.
- D. Emergency medical technician who treated victims of a car bombing at a department store.
Correct Answer: D
Rationale: The EMT experienced an adventitious crisis (bombing), warranting critical incident stress debriefing due to the traumatic nature of the event.
Which premise is most useful to a nurse planning crisis intervention for any patient?
- A. The patient is experiencing a state of disequilibrium.
- B. The patient is experiencing a type of mental illness.
- C. The patient poses a threat of violence to others.
- D. The patient has a high potential for self-injury.
Correct Answer: A
Rationale: Disequilibrium is universal in crisis, representing a struggle for equilibrium. Other options are not always applicable.