An older adult with Lewy body dementia... Which nursing diagnosis has priority?

Correct Answer: A

Rationale: In this scenario, the correct nursing diagnosis with the highest priority is Option A: Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision. This diagnosis takes precedence because safety is a fundamental need in nursing care, especially in psychiatric emergencies involving older adults with Lewy body dementia. Option B, wandering related to confusion and disorientation, is important but falls secondary to the risk of injury. While wandering poses risks, the immediate concern is preventing harm to the patient. Option C, chronic confusion related to degenerative changes, addresses a symptom rather than a potential life-threatening situation. Option D, insomnia related to sleep disruptions, is also significant but does not pose an immediate threat to the patient's safety compared to the risk of injury due to poor judgment and cognitive impairments. Educationally, understanding the priority of nursing diagnoses in psychiatric emergencies is crucial for providing effective and safe care. By prioritizing the risk for injury, nurses can implement strategies to ensure the patient's safety and prevent harm, which is foundational in psychiatric emergency nursing. It is essential for nurses to continuously assess and prioritize patient needs to deliver optimal care in these challenging situations.

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: 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: 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.