Nokea
An adult seeks counseling after the spouse is murdered. The adult angrily says, 'I hate the monster that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict.' What is the nurse's highest priority question?
- A. What do you mean when you say 'monster'?
- B. What resources do you need to help you cope with this situation?
- C. Would you consider hurting yourself or the person on trial?
- D. Are you having thoughts of hurting yourself or others?
Correct Answer: D
Rationale: The highest nursing priority is safety. The nurse should assess suicidal and homicidal potentials. The incorrect options may be important but not the highest priority.
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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.
Which agency provides coordination in the event of a terrorist attack?
- A. U.S. Food and Drug Administration (FDA)
- B. Environmental Protection Agency (EPA)
- C. National Incident Management System (NIMS)
- D. Federal Emergency Management Agency (FEMA)
Correct Answer: C
Rationale: NIMS provides a systematic approach to coordinate disaster response across various agencies and organizations.
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.
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.
A patient visiting the crisis clinic for the first time asks, 'How long will I be coming here?' The nurse's reply should consider that the usual duration of crisis intervention is how long in weeks?
- A. 1 to 2
- B. 3 to 4
- C. 4 to 6
- D. 6 to 12
Correct Answer: C
Rationale: The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 6 weeks.