An emergency department nurse assesses an unresponsive victim... Which question is most important...?

Correct Answer: B

Rationale: In a psychiatric emergency nursing scenario where an unresponsive victim is being assessed, the most important question among the options provided is B) Has the victim consumed any alcohol? The correct answer is crucial because alcohol consumption can lead to altered mental status, unconsciousness, and can mimic psychiatric symptoms. It is essential to assess for alcohol ingestion in an unresponsive patient to determine if their condition is a result of intoxication, which would require specific interventions and management. Option A) Does the victim have any kidney disease? is not the most important question in this scenario because kidney disease, while important to assess for in a comprehensive health history, is less likely to be immediately relevant in an unresponsive psychiatric emergency situation. Option C) What time was she given salty water? is not as critical as assessing for alcohol consumption in this scenario. Salty water intake may not be directly related to the patient's current condition of being unresponsive, and addressing this question may not provide immediate insight into the patient's presentation. Option D) Did you witness the rape? is also not the most important question to ask initially in an unresponsive psychiatric emergency assessment. While this question may be important in a different context, such as a sexual assault evaluation, it is not the priority when dealing with an unresponsive patient with potential alcohol intoxication. Educationally, this question highlights the importance of thorough assessment and prioritization in psychiatric emergency nursing. It emphasizes the significance of considering substance abuse as a potential cause of altered mental status and the need to address immediate concerns to provide appropriate and timely care to patients in psychiatric crises.

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.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Cocaine. When assessing a patient in a psychiatric emergency with symptoms like abdominal pain, restlessness, irritability, and malnourishment, it is crucial to consider substance abuse as a potential cause. Cocaine is a stimulant drug that can cause abdominal pain, restlessness, and irritability, aligning with the patient's presentation. Alcohol (option A) could also cause abdominal pain and behavioral changes, but in this case, the patient's symptoms are more indicative of stimulant use rather than alcohol intoxication. Amphetamines (option B) can present similarly to cocaine but are less commonly associated with abdominal pain specifically. Cannabis (option C) is unlikely to cause the symptoms described in the scenario. Educationally, this question highlights the importance of considering substance abuse in psychiatric emergencies and the need to differentiate between various substances based on their effects and presentation. Understanding the signs and symptoms of different substances can help nurses provide appropriate care and interventions for patients presenting with similar complaints.