A 28-year-old paramedic presents for an independent medical examination. He has been on long-term disability for 2 years following an emergency response to a motor vehicle collision that involved fatalities. There is no previous psychiatric or substance use history. He states that he is improving. His wife agrees but notes that he has 'a very quick temper and breaks stuff when he is frustrated.' He reports feeling anxious about returning to work and feeling that 'people are out to get me.' He admits that he sometimes hears 'voices and people screaming.' What is the MOST likely diagnosis?

Correct Answer: D

Rationale: The most likely diagnosis for the 28-year-old paramedic described in the scenario is D) Posttraumatic stress disorder (PTSD). This diagnosis is supported by his history of being involved in a traumatic event with fatalities during his work as a paramedic, his reported anxiety about returning to work, his auditory hallucinations ("voices and people screaming"), and his hypervigilance ("people are out to get me"). Option A) Persistent depressive disorder with mood-congruent psychotic features is less likely because the primary symptoms described are related to anxiety, paranoia, and auditory hallucinations, which are more indicative of PTSD than depressive disorder with psychotic features. Option B) Malingering is unlikely as there is no evidence or motive provided in the scenario to suggest that the paramedic is intentionally faking or exaggerating his symptoms for secondary gain. Option C) Unspecified schizophrenia spectrum and other psychotic disorder is less likely as the symptoms described are more consistent with a trauma-related disorder like PTSD rather than a primary psychotic disorder like schizophrenia. Educationally, understanding the differentiation between these diagnoses is crucial for healthcare professionals, especially in emergency and psychiatric settings, to provide accurate assessments, interventions, and referrals for individuals experiencing mental health challenges following traumatic events. Recognizing the symptoms and diagnostic criteria for PTSD can lead to appropriate treatment and support for individuals like the paramedic in this scenario.

Correct Answer: C

Rationale: In a psychiatric emergency nursing context, identifying warning signs of suicide is crucial for timely intervention. The correct answer, giving away sweaters, provides the strongest clue of an impending suicide attempt. This behavior can indicate a sense of finality and detachment from possessions, common in individuals contemplating suicide. Excessive crying (Option B) is a common emotional response to stress and failure, but it is not as specific to suicide risk as giving away belongings. Calling parents (Option A) shows a desire for connection and support, which may actually serve as a protective factor against suicide. Staying alone in a dorm room (Option D) is concerning but not as indicative of imminent risk as giving away personal items. Educationally, discussing these warning signs can help nurses and healthcare professionals in psychiatric settings to develop a keen awareness of subtle cues that may signal an impending suicide attempt. By understanding these behaviors, they can intervene early and provide necessary support and interventions to prevent harm.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Guilt. The parents' response of "We should have seen this coming. We did not do enough" indicates feelings of responsibility and blame for not preventing their child's suicide attempt. This reflects guilt, as they are holding themselves accountable for the situation. Option B) Denial does not apply in this context because the parents are acknowledging the reality of the situation and their role in it. Option C) Shame is not the most appropriate choice as shame typically involves a sense of embarrassment or disgrace, which is not evident in the parents' response. Option D) Rescue feelings also do not fit as the parents' statement does not convey a desire to rescue their child but rather a sense of regret and accountability. From an educational perspective, understanding the emotions and reactions of family members in psychiatric emergency situations is crucial for nurses providing care. Recognizing and addressing feelings of guilt in parents can help in providing appropriate support and counseling to prevent further distress or negative outcomes. By choosing the correct answer and understanding why the other options are not applicable, nurses can enhance their communication skills and empathetic response in such sensitive situations.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Establish rapport with the patient. Establishing rapport is crucial in a psychiatric emergency situation as it helps to build trust and create a safe environment for the patient to express their thoughts and feelings. By establishing rapport, the nurse can create a foundation for effective communication and assessment. Option A) Assess lethality of suicide plan may seem important, but in this case, the immediate priority is to establish a connection with the patient to ensure they feel heard and supported. Jumping straight to assessing the lethality of the suicide plan without establishing rapport can lead to the patient shutting down or feeling judged, hindering effective assessment. Option B) Encourage expression of anger is not the most appropriate initial response in this situation. While acknowledging and validating the patient's emotions is important, the primary focus should be on building a therapeutic relationship through rapport building. Option D) Determine risk factors for suicide is also important but should come after rapport has been established. Without a foundation of trust and open communication, the patient may not be willing to disclose their risk factors or engage in a thorough assessment. In an educational context, this question highlights the significance of therapeutic communication and relationship-building skills in psychiatric nursing. It underscores the importance of empathy, active listening, and creating a safe space for patients to express their emotions, especially in sensitive and potentially life-threatening situations like this one. By prioritizing rapport building, nurses can lay the groundwork for effective assessment, intervention, and support for patients experiencing psychiatric emergencies.

Correct Answer: A

Rationale: In a psychiatric emergency nursing context, the behavior that best demonstrates aggression is option A) Stomping away from the nurses station, going to the hallway, and grabbing a tray from the meal cart. This behavior shows physical actions that can potentially escalate into a violent outburst, posing a risk to the individual and others. This type of behavior requires immediate assessment and intervention to prevent harm. Option B) of bursting into tears and withdrawing to cry on a bed, while distressing, does not exhibit aggression but rather indicates emotional distress and a need for emotional support. Option C) of expressing anger verbally is assertive but not necessarily aggressive, as the individual is communicating their feelings in a non-violent manner. Option D) of refusing medication is a form of resistance or non-compliance, rather than aggression. In an educational context, it is crucial for psychiatric emergency nurses to be able to accurately identify behaviors that signal aggression to intervene effectively and prevent potential harm. Understanding the nuances of different behaviors helps nurses tailor their approach to de-escalation techniques, ensuring the safety and well-being of both the individual in crisis and the healthcare team.