A woman was found confused and disoriented after being abducted and raped... What is the woman’s level of anxiety?

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Severe. The woman in this situation has experienced a traumatic event involving abduction and rape, which are highly distressing and can lead to severe psychological consequences. It is crucial to recognize that such traumatic experiences can result in an overwhelming level of anxiety, fear, and distress in the individual. Option A) Weak and Option B) Mild are incorrect because given the nature of the trauma experienced by the woman, it is highly unlikely that her anxiety level would be categorized as weak or mild. Option C) Moderate may seem plausible, but considering the extreme nature of the events she has gone through, it is more appropriate to classify her anxiety level as severe. Educationally, this question highlights the importance of understanding the psychological impact of traumatic events, especially in the context of psychiatric emergency nursing. It emphasizes the need for nurses to assess and recognize the severity of anxiety in individuals who have experienced trauma, in order to provide appropriate and timely interventions to support their mental health and well-being. By accurately identifying the woman's level of anxiety as severe in this case, nurses can ensure she receives the necessary care and support to help her cope with the aftermath of such a traumatic experience.

Correct Answer: C

Rationale: The correct answer is option C, "I’m sleeping better although I still have an occasional nightmare." This response demonstrates successful reorganization after the rape incident. It indicates progress in coping with the trauma as the individual is experiencing improved sleep, despite occasional nightmares, which is a common symptom following a traumatic event. This statement shows resilience and adaptation to the situation. Option A talks about a rash on the buttocks, which is not related to successful reorganization after a traumatic event and does not address the emotional impact of the assault. Option B mentioning triggering the attack implies self-blame, which is not indicative of successful reorganization. It suggests the individual is attributing fault to themselves for the assault, which is counterproductive in the healing process. Option D focuses on weight loss, which is unrelated to the emotional recovery process from a traumatic experience like rape. It does not provide any insight into the individual's emotional well-being or progress in coping with the aftermath of the assault. In an educational context, this question assesses the understanding of successful reorganization and coping mechanisms in psychiatric emergency nursing. It highlights the importance of recognizing positive signs of recovery and resilience in individuals who have experienced traumatic events such as rape. It also emphasizes the need for sensitive and supportive care for survivors of sexual assault in a psychiatric emergency setting.

Correct Answer: B

Rationale: In this scenario, option B is the correct answer as it describes consensual sex rather than rape. The key factor here is consent. Although the woman may have initially felt pressured or hesitant, she ultimately made the decision to engage in oral sex. Consent means that an individual willingly agrees to engage in sexual activity without any form of coercion or force. Option A describes non-consensual sex as the wife clearly objects, indicating lack of consent. Option C depicts a situation of sexual assault where the person is forcibly subjected to anal penetration after being beaten and robbed. Option D illustrates a clear case of rape as the unconscious patient is unable to give consent. In an educational context, it is crucial for healthcare providers, especially those in psychiatric emergency nursing, to understand the nuances of consent and recognize the signs of non-consensual sexual encounters. By knowing the differences between consensual sex and rape, nurses can provide appropriate care and support to individuals who have experienced sexual violence. It is essential to uphold ethical principles and legal obligations when dealing with such sensitive situations in healthcare settings.

Correct Answer: B

Rationale: In a psychiatric emergency involving an unconscious teenager, the priority action by the nurse should focus on maintaining physiologic stability, which is option B. This is the correct answer because ensuring the teenager's physiological stability is crucial for their immediate well-being and survival. Physiological stability encompasses monitoring vital signs, ensuring adequate oxygenation, and addressing any life-threatening issues promptly. Option A, preserving rape evidence, while important in cases of sexual assault, is not the priority in this scenario where the teenager's life is at immediate risk. Option C, determining what drugs were ingested, is also important but not the priority when the patient is unconscious and in need of stabilization. Option D, obtaining a description of the rape from a friend, is not a priority as the focus should be on the teenager's physiological needs first. In an educational context, it is essential for nurses to prioritize actions based on the urgency of the situation. Understanding the principles of emergency care and triage is fundamental for nurses working in psychiatric or any other healthcare setting to provide safe and effective care to patients in critical conditions. By prioritizing physiological stability, nurses can ensure the best possible outcomes for their patients in emergency situations.

Correct Answer: A

Rationale: In the context of a psychiatric emergency in the emergency department, the correct answer is A) Camera. The rationale behind this is that a camera would be essential for documenting any physical injuries or evidence of trauma on the patient's body. This documentation is crucial for legal and medical purposes, as well as for continuity of care. The incorrect options are B) Body map, C) DNA swabs, and D) Pulse oximeter. A body map is not as essential in an acute psychiatric emergency situation as immediate visual documentation with a camera. DNA swabs are not typically needed in a psychiatric emergency unless there is a specific legal or forensic requirement. A pulse oximeter, while useful in assessing vital signs, is not directly related to documenting physical evidence in a psychiatric emergency. In an educational context, understanding the rationale behind the need for specific equipment in different clinical situations is crucial for nurses to provide effective and comprehensive care. By knowing why certain equipment is necessary, nurses can prioritize their interventions and ensure they are meeting the needs of the patient in that particular scenario.