Author Question: The nurse is performing a crisis assessment on a patient who is experiencing crisis due to a recent ... (Read 38 times)

K@ · **on:** Jul 19, 2018

The nurse is performing a crisis assessment on a patient who is experiencing crisis due to a recent divorce. Which statement made by the patient will alert the nurse that the patient is experiencing the exhaustion phase of crisis?

1. I can't believe this is happening to me.
2. I have called my mom to help me with the kids.
3. I am tired from moving all of my belongings into a new house.
4. I just can't seem to cope anymore. I am not sure what I am going to do.

Question 2

The nurse is caring for a patient in crisis who has recently returned from military service in an active war zone. When initially assessing this patient, which concepts will the nurse apply regarding the type of crisis the patient is experiencing?

Select all that apply.
1. Determining the client's adaptation to the crisis guides the priority nursing actions.
2. Determining the trauma category the client is experiencing guides the priority nursing action.
3. Providing the client with education regarding type I trauma related to his or her military service.
4. Providing the client with education regarding type II trauma related to his or her military service.
5. Determining the client's degree of trust in trusted authorities during his or her military service.

kxciann · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

Answer: 4
Explanation: Classifying the stage of adaptation displayed by the individual is a component of the initial crisis assessment. The General Adaptation Syndrome describes three basic stages through which most individuals progress during attempts to cope with significant stressors: alarm, resistance, and exhaustion. The statement, I just can't seem to cope anymore. I am not sure what I am going to do is characteristic of the exhaustion phase of crisis. Exhaustion occurs when coping resources are low or depleted. The statement, I can't believe this is happening to me best describes the alarm stage of crisis, which occurs during the initial reaction to a crisis. The statements I have called my mom to help me with the kids and I am tired from moving all of my belongings into a new house best describe the resistance stage of crisis when the individual mobilizes resources in an effort to attempt to resolve the stressor.

Answer to Question 2

Answer: 1, 2, 4, 5
Explanation: The patient described in the scenario is likely experiencing a type II trauma. Type I trauma experiences are one-time, limited experiences that generally are less likely to cause PTSD, whereas type II trauma experiences are recurrent or chronic and are more likely to cause PTSD. Assessment of the type of trauma and how the individual is adapting to it helps determine an appropriate approach to crisis care and the risk of psychiatric sequelae. Providing the patient with education about type II, not type I traumas, will help the patient understand the condition and will provide the patient with resources and interventions to help with this crisis. Loss of trust in those whom an individual has trusted during the trauma period increases risk for posttraumatic stress disorder (PTSD), so it will be important for the nurse to assess how the patient views authorities associated with the period of military service.