A 43 year old man has felt faint and fallen when trying to stand from a chair. Investigations: Sodium 119 mmol/L, Serum osmolality 260 mOsmol/kg. Which is the most likely cause?

Correct Answer: D

Rationale: In this case, the correct answer is D) Stroke. The presentation of a 43-year-old man with a low sodium level (hyponatremia) and symptoms of feeling faint and falling is concerning for a stroke, particularly a posterior circulation stroke affecting the brainstem. Hyponatremia is a common electrolyte abnormality seen in stroke patients due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Option A) Adrenal insufficiency is less likely as the symptoms and lab findings are more indicative of a neurological issue rather than an endocrine problem. Option B) Dehydration would typically present with hypernatremia rather than hyponatremia. The clinical scenario of feeling faint and falling is not consistent with dehydration. Option C) Medication side-effects can cause hyponatremia, but in this case, the presentation is more indicative of a neurological issue like a stroke. Educationally, understanding the relationship between electrolyte imbalances like hyponatremia and neurological conditions such as stroke is crucial for nurses working in psychiatric emergency settings. Recognizing the signs and symptoms of stroke, especially in atypical populations like younger individuals, is vital for prompt intervention and optimal patient outcomes. This case highlights the importance of holistic assessment and critical thinking in psychiatric emergency nursing practice.

Correct Answer: A

Rationale: The correct answer is option A) Coeliac disease. In an 18-month-old girl presenting with poor weight gain and chronic loose stools, Coeliac disease is the most likely underlying cause. Coeliac disease is an autoimmune disorder triggered by gluten ingestion, leading to damage in the small intestine and impairing nutrient absorption, resulting in poor weight gain and gastrointestinal symptoms like loose stools. Option B) Cow's milk protein allergy is less likely in this case because although it can also present with gastrointestinal symptoms, it typically manifests more acutely after exposure to cow's milk proteins, unlike the chronic nature of symptoms described in the scenario. Option C) Crohn's disease is less common in infants and toddlers, and it usually presents with a different pattern of symptoms, such as abdominal pain, bloody stools, and more systemic symptoms beyond poor weight gain and loose stools. Option D) Lactose intolerance is also less likely in this case as it would typically present with symptoms like bloating, gas, and diarrhea shortly after consuming lactose-containing foods, rather than the chronic and persistent nature of symptoms described in the scenario. In an educational context, understanding the differential diagnosis of gastrointestinal symptoms in pediatric patients is crucial for healthcare providers, especially in identifying serious conditions like Coeliac disease early to initiate appropriate management and prevent long-term complications. This case highlights the importance of considering various causes of poor weight gain and chronic loose stools in pediatric patients to provide optimal care and improve outcomes.

Correct Answer: D

Rationale: In this scenario, the most likely diagnosis for a 31-year-old woman presenting with increasing shortness of breath and left-sided pleuritic chest pain for 1 week is a pulmonary embolism (PE). A PE occurs when a blood clot travels to the lungs, blocking one or more pulmonary arteries. The correct answer (D) is PE because the symptoms of shortness of breath and pleuritic chest pain are classic signs of a PE. Moreover, the risk factors for PE, such as recent surgery, prolonged immobility, or use of oral contraceptives, are common in young women. Option A, bronchiectasis, is less likely as it typically presents with chronic cough, sputum production, and recurrent respiratory infections. Option B, lung cancer, is less likely in a young non-smoking woman and would typically present with symptoms like persistent cough, weight loss, and hemoptysis. Option C, pneumonia, is less likely as it usually presents with fever, productive cough, and focal chest signs on examination. Educationally, understanding the presentation of PE is crucial in the field of psychiatric emergency nursing as patients with psychiatric conditions may have higher risks of developing conditions like PE due to factors such as sedentary lifestyle, obesity, or medication side effects. Nurses must be adept at recognizing atypical presentations of common conditions in psychiatric patients to ensure timely and appropriate interventions.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Phrenic nerve. The phrenic nerve innervates the diaphragm, the primary muscle responsible for breathing. Damage to the phrenic nerve can lead to difficulty breathing, as seen in the case of the man stabbed in the neck. Option A) Greater splanchnic nerve is not involved in respiratory function but rather plays a role in transmitting visceral sensory information. Option C) Recurrent laryngeal nerve is responsible for vocal cord movement and sensation in the larynx, not breathing. Option D) Spinal accessory nerve controls certain neck muscles, but not those directly involved in breathing. Understanding the anatomy and function of these nerves is crucial for nurses in a psychiatric emergency setting. In emergencies where respiratory distress is involved, identifying the nerve affected can help in providing appropriate care and interventions to support the patient's breathing. This knowledge enhances the nurse's ability to assess, intervene, and communicate effectively with the healthcare team in managing such critical situations.

Correct Answer: D

Rationale: In this scenario, the most appropriate management approach for a 35-year-old woman with recurrent retrosternal discomfort after eating is option D) Gastroenterology clinic referral. This choice is correct because the symptoms described suggest a possible gastrointestinal issue, such as gastroesophageal reflux disease (GERD) or a peptic ulcer, which would require further evaluation and management by a specialist in gastroenterology. Option A) Barium swallow is not the most appropriate initial step in this case because it is more focused on evaluating the structure and function of the esophagus, which may not provide a definitive diagnosis for the underlying cause of the symptoms. Option B) Chest X-ray is unlikely to be helpful in diagnosing gastrointestinal issues, as it primarily focuses on imaging the structures of the chest and lungs, rather than the digestive system. Option C) CT scan of the thorax is not the first-line investigation for evaluating gastroesophageal issues unless there are specific indications for thoracic pathology, which are not evident in this case. Educationally, understanding the rationale behind selecting the appropriate management approach based on the presenting symptoms is crucial in developing clinical reasoning skills. By recognizing the importance of a gastroenterology clinic referral in this case, healthcare providers can ensure that patients receive timely and appropriate care for their gastrointestinal concerns, ultimately improving patient outcomes and satisfaction.