What is a nurse’s legal responsibility if child abuse or neglect is suspected?

Correct Answer: C

Rationale: In a psychiatric emergency, when child abuse or neglect is suspected, a nurse's legal responsibility is to report the suspicion according to state regulations. This is crucial to protect the child's safety and well-being. Reporting ensures that appropriate authorities can investigate and intervene to protect the child from further harm. Option A, discussing findings with the child's parent and healthcare provider, is not appropriate in cases of suspected child abuse or neglect as it may jeopardize the child's safety and could lead to interference or intimidation by the abuser. Option B, documenting the observation and suspicion in the medical record, is important for documentation purposes but does not fulfill the legal obligation to report suspected child abuse or neglect to the authorities. Option D, continuing the assessment, is not the immediate priority when child abuse or neglect is suspected. The safety of the child takes precedence over further assessment at that moment. Educationally, it is essential for healthcare professionals, especially nurses, to understand their legal responsibilities in cases of suspected child abuse or neglect. Training and knowledge in recognizing, reporting, and preventing child abuse are vital components of a nurse's role in protecting vulnerable populations. This ensures that healthcare providers act in the best interest of the child and comply with legal and ethical obligations.

Correct Answer: B

Rationale: In the context of a survivor of physical spousal abuse being treated in a psychiatric emergency setting, the most appropriate outcome that should be met before discharge is for the individual to name two community resources for help (Option B). This is the correct choice because it demonstrates proactive engagement in seeking ongoing support and assistance beyond the immediate healthcare setting. Option A, facilitating counseling for the abuser, is not the most appropriate outcome before discharge for the survivor of abuse. The primary focus should be on the survivor's safety and well-being, rather than on interventions for the abuser at this stage. Option C, demonstrating insight into the abusive relationship, while important for the survivor's healing process, may not be an immediate requirement before discharge. Practical steps to ensure ongoing support and safety are more critical in the immediate aftermath of a psychiatric emergency. Option D, reexamining cultural beliefs about marital commitment, is also not the most pressing concern before discharge. While addressing cultural factors is important in the long term, the immediate priority is to ensure the survivor has access to necessary resources and support to address the abuse they have experienced. Educationally, this question highlights the importance of practical and immediate interventions to support individuals experiencing spousal abuse in psychiatric emergency settings. It underscores the significance of connecting survivors with community resources and support systems to ensure their safety and well-being beyond the clinical setting.

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: A

Rationale: In a psychiatric emergency involving intimate partner abuse, ensuring the safety and well-being of the victim is the top priority. Option A, keeping a cell phone fully charged, is the correct choice because it allows the victim to quickly contact emergency services, a crisis hotline, or a trusted individual for help. In such situations, immediate access to communication is crucial for seeking assistance and protection. Option B, hiding money for new clothes, is not the most appropriate response as it focuses on material possessions rather than safety. While economic empowerment is important, it is secondary to ensuring the victim's immediate safety and access to support services. Option C, having the phone number for the nearest shelter, is a valuable resource for the victim to seek refuge and support. However, in the context of a psychiatric emergency, immediate communication through a fully charged cell phone takes precedence as it allows for real-time assistance. Option D, taking toys to amuse children for 2 days, although thoughtful, is not as critical in a psychiatric emergency involving intimate partner abuse. While addressing the needs of children is important, the primary focus should be on ensuring the safety and protection of the victim through immediate communication and access to support services. Educationally, this question emphasizes the importance of prioritizing safety and quick access to help in psychiatric emergencies, particularly in cases of intimate partner abuse. It highlights the significance of effective communication tools and resources in ensuring the well-being of individuals in vulnerable situations. By understanding and applying these principles, healthcare professionals can better support and advocate for victims of intimate partner abuse in psychiatric emergencies.

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.