An adult seeks counseling after the spouse was murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority response?

Correct Answer: D

Rationale: In this scenario, the correct response is option D: "Are you having thoughts of hurting yourself or others?" This is the highest priority response because the individual's statement indicates intense anger and distress, which could potentially escalate to harmful thoughts or actions. The nurse needs to assess the client's risk of harm to ensure their safety and the safety of others. Option A suggests medication, which may be necessary at some point but is not the priority in this immediate situation. Option B focuses on resources, which is important but not as critical as assessing for safety. Option C addresses support from family and friends, which is valuable but does not directly address the potential for harm. Educationally, this question highlights the importance of recognizing cues indicating potential harm or risk in clients experiencing intense emotions. It emphasizes the need for nurses to prioritize safety assessments in such situations to provide appropriate care and support. Understanding the significance of addressing safety concerns promptly is crucial in mental health and behavioral nursing practice.

Correct Answer: B

Rationale: This community has experienced a catastrophic event. There are five phases of the disaster management continuum. The nurses' activities applied to mitigation (attempts to limit a disaster's impact on human health and community function) and response (actual implementation of a disaster plan). Preparedness occurs before an event. Recovery actions focus on stabilizing the community and returning it to its previous status. Evaluation of the response efforts apply to the future.

Correct Answer: B

Rationale: The conference room would provide a quiet, private area with few distractions, separate from other patient areas and effective for teaching and learning about a private topic. The auditorium is too large, and members' anxiety or lack of trust might lead them to spread out too far from each other, interfering with group process. The day room and the music therapy room are too busy and exposed, reducing privacy and increasing distractions.

Correct Answer: A

Rationale: Patients with schizophrenia almost universally have problems associated with everyday living in the community, so discussing ways to manage the illness would be an important aspect of psychoeducation. Discussing concerns about daily life would be a goal to which each could relate. Developing trust and cohesion is desirable but is not the priority outcome of a psychoeducational group. Understanding unconscious motivation would not be addressed. Insight would be difficult for a patient with residual schizophrenia because of the tendency toward concrete thinking.

Correct Answer: C

Rationale: In the field of nursing, caring for clients and families experiencing death and dying can take a significant emotional toll on the nurse. Self-care is crucial to ensure the nurse's own health and well-being. Option A) Reflection is an important part of self-care for a nurse. Reflecting on experiences helps nurses process their emotions, learn from their interactions, and improve their practice. It allows them to gain insights and grow personally and professionally. Option B) Peer support is another essential aspect of self-care. Connecting with colleagues who understand the challenges of the profession can provide emotional support, empathy, and a sense of community. Peer support can reduce feelings of isolation and burnout. Option D) Seeking counseling services when needed is also a vital component of self-care. Counseling can provide a safe space for nurses to express their feelings, work through emotional issues, and develop coping strategies. It can help prevent the negative impact of stress and trauma on mental health. Option C) Isolating is the incorrect choice. Isolating oneself can lead to feelings of loneliness, increased stress, and a lack of emotional support. It can exacerbate the emotional burden of caring for dying patients and families, potentially leading to burnout and compassion fatigue. In an educational context, understanding the importance of self-care is crucial for nursing students and practicing nurses. By recognizing the need for self-care strategies such as reflection, peer support, and seeking counseling when necessary, nurses can better cope with the emotional demands of their profession and maintain their overall well-being. Identifying behaviors like isolating as detrimental to self-care reinforces the importance of seeking support and connection within the nursing community.