A nurse directs the intervention team... Which actions will the nurse direct...?

Correct Answer: A

Rationale: In a psychiatric emergency scenario, the correct action for the nurse to direct the intervention team to appoint a person to clear a path and open doors (Option A) is crucial for several reasons. Firstly, ensuring a clear path and open doors facilitates a safe and efficient approach to the patient, preventing any potential obstacles or triggers that may escalate the situation further. This action prioritizes safety for both the patient and the healthcare team. Option B, which suggests quickly approaching and taking the closest extremity, is incorrect in a psychiatric emergency as it can be perceived as aggressive and may escalate the situation, leading to potential harm to both the patient and the healthcare team. Option C, selecting the person who will communicate with the patient, while important in psychiatric emergencies, is not the immediate priority when the team is first approaching the situation. Safety and ensuring a calm environment take precedence over communication in the initial stages of a psychiatric emergency. Option D, moving behind the patient when not looking, is also an incorrect action as it can be interpreted as sneaky or distrustful behavior by the patient, potentially increasing their agitation and leading to a loss of trust in the healthcare team. In an educational context, understanding the appropriate steps to take in a psychiatric emergency is crucial for healthcare professionals working in various settings. Proper training and knowledge of de-escalation techniques, communication strategies, and safety protocols are essential in effectively managing psychiatric emergencies and ensuring the well-being of both patients and healthcare providers.

Correct Answer: C

Rationale: In a psychiatric emergency, when child abuse or neglect is suspected, a nurse's legal responsibility is to report the suspicion according to state regulations. This is crucial to protect the child's safety and well-being. Reporting ensures that appropriate authorities can investigate and intervene to protect the child from further harm. Option A, discussing findings with the child's parent and healthcare provider, is not appropriate in cases of suspected child abuse or neglect as it may jeopardize the child's safety and could lead to interference or intimidation by the abuser. Option B, documenting the observation and suspicion in the medical record, is important for documentation purposes but does not fulfill the legal obligation to report suspected child abuse or neglect to the authorities. Option D, continuing the assessment, is not the immediate priority when child abuse or neglect is suspected. The safety of the child takes precedence over further assessment at that moment. Educationally, it is essential for healthcare professionals, especially nurses, to understand their legal responsibilities in cases of suspected child abuse or neglect. Training and knowledge in recognizing, reporting, and preventing child abuse are vital components of a nurse's role in protecting vulnerable populations. This ensures that healthcare providers act in the best interest of the child and comply with legal and ethical obligations.

Correct Answer: D

Rationale: The correct answer is D) Document injuries with a body map. In a psychiatric emergency scenario where a young adult has had multiple absences, it is crucial for the nurse to document any injuries with a body map. This action is essential for assessing the severity and pattern of injuries, ensuring proper medical treatment, and providing accurate information to other healthcare professionals involved in the individual's care. Calling the police (Option A) may not be warranted unless there is an immediate threat to the individual's safety or others. Arranging for hospitalization (Option B) may be premature without a clear assessment of the individual's physical and mental health status. Calling the adult protective agency (Option C) is not indicated unless there is evidence of abuse or neglect, which is not specified in the scenario. Educationally, understanding the importance of thorough documentation in psychiatric emergencies is crucial for nurses working in mental health settings. Documenting injuries accurately can aid in the overall assessment, treatment planning, and continuity of care for individuals experiencing psychiatric crises. This skill is vital for providing holistic and effective care in psychiatric emergencies.

Correct Answer: B

Rationale: In the context of a survivor of physical spousal abuse being treated in a psychiatric emergency setting, the most appropriate outcome that should be met before discharge is for the individual to name two community resources for help (Option B). This is the correct choice because it demonstrates proactive engagement in seeking ongoing support and assistance beyond the immediate healthcare setting. Option A, facilitating counseling for the abuser, is not the most appropriate outcome before discharge for the survivor of abuse. The primary focus should be on the survivor's safety and well-being, rather than on interventions for the abuser at this stage. Option C, demonstrating insight into the abusive relationship, while important for the survivor's healing process, may not be an immediate requirement before discharge. Practical steps to ensure ongoing support and safety are more critical in the immediate aftermath of a psychiatric emergency. Option D, reexamining cultural beliefs about marital commitment, is also not the most pressing concern before discharge. While addressing cultural factors is important in the long term, the immediate priority is to ensure the survivor has access to necessary resources and support to address the abuse they have experienced. Educationally, this question highlights the importance of practical and immediate interventions to support individuals experiencing spousal abuse in psychiatric emergency settings. It underscores the significance of connecting survivors with community resources and support systems to ensure their safety and well-being beyond the clinical setting.

Correct Answer: B

Rationale: In a psychiatric emergency involving an older woman with Alzheimer's disease, securing additional resources for evening and night care (Option B) is the nursing intervention with the highest priority. This is because individuals with Alzheimer's disease often experience increased confusion, agitation, and behavioral disturbances during the evening and nighttime, a phenomenon known as sundowning. By ensuring there are adequate resources in place during these times, the caregiver can prevent potential crises, ensure the safety of the patient, and provide necessary support. Option A, teaching the caregiver about sundowners syndrome, is not the priority as understanding the syndrome alone does not address the immediate need for additional resources for care. Option C, supporting the caregiver to grieve the loss of abilities, though important for long-term emotional support, is not the immediate priority in a psychiatric emergency. Option D, teaching the family how to give physical care more effectively, is also important but falls lower in priority compared to securing additional resources for evening and night care, which directly addresses the safety and well-being of the patient in the immediate situation. In an educational context, understanding the prioritization of nursing interventions in psychiatric emergencies is crucial for providing effective care to patients with Alzheimer's disease and their caregivers. By recognizing the urgency of certain interventions over others, nurses can ensure that critical needs are met promptly, leading to better patient outcomes and caregiver support.