A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to:

Correct Answer: C

Rationale: The correct answer is C) Suicide potential. The SAD PERSONS scale is a tool used in psychiatric assessment to evaluate suicide risk factors. It assesses various aspects such as sex, age, depression, previous suicide attempts, ethanol abuse, rational thinking loss, social supports lacking, organized plan, and no spouse. These factors contribute to determining an individual's suicide potential, making option C the most relevant data obtained through this tool. Option A) Current stress level is incorrect because while stress can be a contributing factor to psychiatric emergencies, the SAD PERSONS scale specifically focuses on suicide risk factors, not general stress levels. Option B) Mood disturbance is incorrect as the SAD PERSONS scale is more focused on risk factors for suicide rather than mood disturbances, which may be assessed through other tools or assessments. Option D) Level of anxiety is incorrect as the SAD PERSONS scale does not primarily assess anxiety levels. While anxiety may play a role in psychiatric emergencies, it is not the main focus of this particular tool. In an educational context, understanding the purpose and application of assessment tools like the SAD PERSONS scale is crucial for healthcare providers working with individuals in psychiatric emergencies. By correctly applying tools like this, nurses and other professionals can gather essential data to identify and address the specific risk factors associated with suicide potential, ultimately improving patient care and safety.

Correct Answer: C

Rationale: The most helpful response for a nurse to make when a patient states, "I am considering committing suicide," is option C: "Bringing up these feelings is a very positive action on your part." This response is the most appropriate because it validates the patient's feelings and acknowledges their courage in expressing such thoughts. It opens the door for further dialogue and exploration of the patient's emotions and experiences, which is crucial in assessing the level of risk and providing appropriate support and interventions. Option A is incorrect as it may come across as dismissive or minimizing the seriousness of the situation. Option B, while well-intentioned, may not be the most suitable first response as hospitalization should be considered based on a thorough assessment of the patient's risk level. Option D, focusing on the positive aspects of life, may overlook the patient's immediate distress and need for validation and support in that moment of crisis. Educationally, it is vital for healthcare providers to approach discussions around suicide with empathy, active listening, and a non-judgmental attitude. Validating the patient's feelings and encouraging open communication are key components of effective crisis intervention and suicide prevention strategies. By understanding the rationale behind each response, nurses can enhance their communication skills and provide better care for individuals in psychiatric emergencies.

Correct Answer: C

Rationale: In this scenario, option C, "Paranoid delusions of being followed by alien monsters," predicts the highest risk for directing violent behavior toward others. This is because paranoid delusions involve strong beliefs of being threatened or persecuted, which can lead to a heightened sense of fear and a distorted perception of reality. Individuals experiencing paranoid delusions may act aggressively in self-defense or as a response to perceived threats, potentially resulting in violent behavior towards others. Option A, "Major depression with delusions of worthlessness," typically does not pose a direct risk of violent behavior towards others. Individuals with major depression and delusions of worthlessness are more likely to exhibit symptoms of self-harm or suicide rather than directing violence outward. Option B, "Obsessive-compulsive disorder; performs many rituals," is not typically associated with an increased risk of directing violent behavior towards others. Individuals with OCD are more focused on managing their anxiety through rituals and compulsions rather than engaging in violent acts towards others. Option D, "Completed alcohol withdrawal; beginning a rehabilitation program," does not inherently indicate a high risk of directing violent behavior towards others. While individuals in recovery from alcohol withdrawal may face challenges, such as emotional instability or cravings, it does not directly correlate with a significant increase in violent behavior towards others. In an educational context, understanding the link between specific psychiatric symptoms and the risk of violent behavior is crucial for healthcare providers, first responders, and mental health professionals. Recognizing the potential for violence in individuals experiencing paranoid delusions can help in implementing appropriate interventions, ensuring safety for both the individual and others in their environment. By analyzing different psychiatric presentations and their associated risks, professionals can make informed decisions and provide targeted support and care for those in need.

Correct Answer: A

Rationale: In a psychiatric emergency, it is crucial for healthcare providers to prioritize safety for both the patient and themselves. Option A, making sure there is adequate physical space between the nurse and the patient, is the correct choice in this scenario. By maintaining a safe distance, the nurse reduces the risk of harm to themselves or the patient if the situation escalates. Option B, moving into a position close to the door, may actually agitate the patient further or make them feel cornered, potentially escalating the situation. Option C, maintaining one arm's-length distance, may not provide enough space in case the patient becomes physically aggressive. Option D is incorrect because engaging the patient in conversation about appropriate behavior is not the immediate priority in a situation where the patient is exhibiting signs of distress or agitation. Educationally, this scenario emphasizes the importance of maintaining safety in psychiatric emergencies. It highlights the need for healthcare providers to assess and respond to situations quickly and appropriately to prevent harm and promote a therapeutic environment for the patient.

Correct Answer: B

Rationale: In this scenario, the statement that requires immediate attention is option B) "My fingers are tingly." This statement indicates a potential physical issue that needs immediate medical evaluation. Tingling in the fingers can be a sign of a serious medical condition such as nerve damage, circulation problems, or even a stroke. In a psychiatric emergency situation, it is crucial to prioritize physical health concerns alongside mental health issues. Option A) "I hate all of you!" may indicate emotional distress or anger, which is common in psychiatric emergencies but does not pose an immediate physical threat. Option C) "You wait until I tell my lawyer." is a threat but does not require immediate attention as it does not imply any imminent harm. Option D) "The other patient started the fight." is an attempt to shift blame and does not pose an immediate physical threat requiring urgent attention. In an educational context, it is important for healthcare providers to be able to quickly assess and prioritize statements made by patients in psychiatric emergencies to ensure the safety and well-being of all individuals involved. Recognizing statements that indicate immediate physical danger is critical in providing timely and appropriate care in such situations.