An older woman diagnosed with Alzheimer’s disease... Which nursing intervention has priority?

Correct Answer: B

Rationale: In a psychiatric emergency involving an older woman with Alzheimer's disease, securing additional resources for evening and night care (Option B) is the nursing intervention with the highest priority. This is because individuals with Alzheimer's disease often experience increased confusion, agitation, and behavioral disturbances during the evening and nighttime, a phenomenon known as sundowning. By ensuring there are adequate resources in place during these times, the caregiver can prevent potential crises, ensure the safety of the patient, and provide necessary support. Option A, teaching the caregiver about sundowners syndrome, is not the priority as understanding the syndrome alone does not address the immediate need for additional resources for care. Option C, supporting the caregiver to grieve the loss of abilities, though important for long-term emotional support, is not the immediate priority in a psychiatric emergency. Option D, teaching the family how to give physical care more effectively, is also important but falls lower in priority compared to securing additional resources for evening and night care, which directly addresses the safety and well-being of the patient in the immediate situation. In an educational context, understanding the prioritization of nursing interventions in psychiatric emergencies is crucial for providing effective care to patients with Alzheimer's disease and their caregivers. By recognizing the urgency of certain interventions over others, nurses can ensure that critical needs are met promptly, leading to better patient outcomes and caregiver support.

Correct Answer: B

Rationale: The correct answer is B) Confusion and disbelief. In the acute phase of rape-trauma syndrome, individuals commonly experience feelings of confusion and disbelief as they try to process and make sense of the traumatic event that has occurred. This initial reaction is a normal response to an overwhelmingly distressing situation such as an abduction and rape. Option A) Decreased motor activity is not indicative of the acute phase of rape-trauma syndrome. While some individuals may experience physical symptoms like immobilization or hyperactivity, decreased motor activity is not a specific hallmark of the acute phase. Option C) Flashbacks and dreams are more commonly associated with the reorganization phase of rape-trauma syndrome, which occurs after the acute phase. During this phase, survivors may experience intrusive memories of the traumatic event in the form of flashbacks or nightmares. Option D) Fears and phobias are symptoms that can occur in various phases of trauma recovery, but they are not specific indicators of the acute phase of rape-trauma syndrome. In the acute phase, individuals are more likely to be overwhelmed by feelings of confusion, disbelief, and emotional distress rather than specific fears or phobias. Educationally, understanding the different phases of rape-trauma syndrome is crucial for healthcare professionals, counselors, and first responders who may encounter survivors of sexual assault. Recognizing the symptoms associated with each phase can help in providing appropriate support and interventions tailored to the survivor's needs at different stages of their recovery process.

Correct Answer: A

Rationale: The correct answer is A) Support the victim to separate issues of vulnerability from blame. This response is the most therapeutic because it acknowledges the victim's feelings of vulnerability while emphasizing that the blame for the assault lies solely with the perpetrator. By validating the victim's emotions and helping them understand that they are not at fault, the nurse creates a safe space for the victim to process their experience and begin the healing process. Option B) Emphasizing the importance of using a buddy system in public places is not as therapeutic in this context because it focuses on prevention strategies rather than addressing the victim's current emotional needs. While safety measures are important, in a psychiatric emergency situation, the immediate concern is providing support and empathy to the victim. Option C) Reassuring the victim that the outcome will be positive may come across as dismissive of the victim's current emotional distress and can invalidate their feelings of fear, anger, or confusion. It is essential to acknowledge and address the victim's emotions rather than trying to prematurely assure them of a positive outcome. Option D) Posing questions about the rape and exploring why it happened can be potentially re-traumatizing for the victim, especially in a psychiatric emergency setting. Delving into the details of the assault without the victim's readiness or consent can exacerbate their distress and hinder the therapeutic communication process. In an educational context, it is crucial for healthcare providers to understand the principles of trauma-informed care and effective communication techniques when dealing with psychiatric emergencies, such as cases of sexual assault. Supporting individuals in a non-blaming and empathetic manner can help build trust, facilitate emotional healing, and empower victims to seek further help and support.

Correct Answer: B

Rationale: The correct answer is B) Male victims often experience physical injuries and are assaulted by more than one person. This response shows empathy, acknowledges the common experiences of male victims, and addresses potential physical injuries and multiple assailants, which are crucial aspects of assessing a psychiatric emergency involving a male victim of assault. Option A is incorrect as it perpetuates harmful gender stereotypes suggesting that men are better equipped to handle emotional pain than women, which is not supported by evidence and can further stigmatize male victims seeking help. Option C is not the best response as it redirects the focus to other male friends who may have been victims, potentially minimizing the individual's experience and needs in that moment. Option D is inappropriate as it places blame on the victim by asking why they think they became a victim of sexual assault, which can be retraumatizing and shift the responsibility away from the perpetrator. In an educational context, it is important for healthcare providers to approach psychiatric emergencies involving victims of assault with sensitivity, empathy, and a trauma-informed lens. Understanding the unique challenges and experiences faced by male victims of assault is crucial in providing appropriate care and support. Acknowledging physical injuries, the possibility of multiple assailants, and offering non-judgmental support are key components of effectively managing such situations.

Correct Answer: D

Rationale: In a psychiatric emergency involving sexual assault, it is crucial for the nurse to provide appropriate support and resources to the victim before discharge. Option D, providing referral information verbally and in writing, is the correct choice because it ensures that the victim has access to further help and support beyond the immediate care provided. This empowers the victim to seek ongoing assistance for their physical, emotional, and psychological needs. Option A, notifying the victim's family, may not be suitable as the victim might not want their family involved or may have strained family relationships. Respect for the victim's autonomy and confidentiality is paramount in such cases. Option B, offering to stay with the patient, is well-intentioned but may not be feasible due to staffing constraints and the need for the victim to access specialized support services. Option C, advising the patient to try not to think about the assault, is inappropriate as it dismisses the seriousness of the trauma experienced and can be harmful to the victim's mental health. In an educational context, understanding the importance of providing appropriate support and resources to victims of sexual assault is critical for healthcare professionals working in psychiatric emergency settings. It underscores the significance of trauma-informed care, empathy, and the ethical considerations involved in caring for individuals who have experienced such traumatic events.