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A patient comes to the crisis center saying, 'I'm in a terrible situation. I don't know what to do.' The triage nurse can initially assume that the patient is experiencing what?
- A. Suicidal ideations
- B. Anxiety and fear
- C. Misperceived reality
- D. Homicidal ideations
Correct Answer: B
Rationale: Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed. None of the other options are supported with behaviors.
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A woman says, 'I can't take anymore! Last year my husband had an affair. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college.' What type of crisis is this person experiencing?
- A. Maturational
- B. Adventitious
- C. Situational
- D. Recurring
Correct Answer: C
Rationale: A situational crisis arises from an external source and involves a loss of self-concept or self-esteem. The series of events described, particularly the daughter's decision, points to external stressors.
Which patient statement best suggests they have returned to a pre-crisis level of functioning?
- A. My boss told me I am doing well and up for a promotion.
- B. I understand that bad things can happen to really good people.
- C. Going to my support group regularly has made a big difference.
- D. I'm much more comfortable asking for help than before my divorce.
Correct Answer: A
Rationale: Resolution of a crisis can result in a return to pre-crisis functioning, or a higher or lower level of functioning. The goal of crisis intervention is a return to at least pre-crisis functioning level. A good job performance evaluation is suggestive of pre-crisis functioning.
An adult tells the nurse, 'I can't take anymore! My mother passed away, my husband lost his job and yesterday my daughter told me she's quitting college and moving in with her boyfriend.' What is the priority nursing diagnosis?
- A. Fear, related to impending breast surgery
- B. Deficient knowledge, related to breast lesion
- C. Ine efectiva coping, related to perceived loss of daughter
- D. Impaired verbal communication, related to spousal estrangement
Correct Answer: C
Rationale: This nursing diagnosis reflects the precipitating event (daughter's actions) causing the crisis. Other options are not supported by the data provided.
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.
A patient comes to the clinic with superficial cuts on the left wrist. The patient is pacing and sobbing. After a few minutes with the nurse, the patient is calmer. What should the nurse ask to determine the patient's perception of the precipitating event?
- A. Tell me why you were crying.
- B. How did your wrist get injured?
- C. How can I help you feel more comfortable?
- D. What was happening just before you started feeling this way?
Correct Answer: D
Rationale: A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events permits the assessment of the precipitating event. Asking 'why' questions are a nontherapeutic communication technique.