Crisis and Mass Disaster

MULTIPLE CHOICE

1. A patient comes to the clinic with superficial cuts on the left wrist. The patient paces around the room sobbing but cringes when approached and responds to questions with only shrugs or monosyllables. Select the nurse’s best initial statement to this patient.
a. “Everything is going to be all right. You are here at the clinic, and the staff will keep you safe.”
b. “I see you are feeling upset. I am going to stay and talk with you to help you feel better.”
c. “You need to try to stop crying so we can talk about your problems.”
d. “Let’s set some guidelines and goals for your visit here.”
ANS: B
A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate the use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patient’s safety. The incorrect responses use nontherapeutic techniques, including false reassurance and giving advice.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 404-405 | Pages: 407-409 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

2. A patient comes to the clinic with superficial cuts on the left wrist. The patient is pacing and sobbing. After a few minutes with the nurse, the patient is calmer. What should the nurse ask to determine the patient’s perception of the precipitating event?
a. “Tell me why you were crying.”
b. “How did your wrist get injured?”
c. “How can I help you feel more comfortable?”
d. “What was happening just before you started feeling this way?”
ANS: D
A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events permits the assessment of the precipitating event. Asking “why” questions is a nontherapeutic communication technique.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 404-405 | Pages: 407-409 TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity

3. A patient comes to the crisis center saying, “I’m in a terrible situation. I don’t know what to do.” The triage nurse can initially assume that the patient is:
a. suicidal.
b. anxious and fearful.
c. misperceiving reality.
d. potentially homicidal.
ANS: B
Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 402-404
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

4. An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The patient told the parents about the uncle’s behavior, but the parents did not believe the adolescent. What type of crisis exists?
a. Maturational
b. Adventitious
c. Situational
d. Organic
ANS: B
An adventitious crisis is a crisis of disaster that is not a part of everyday life; it is unplanned or accidental. Adventitious crises include natural disasters, national disasters, and crimes of violence. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. Situational crisis arises from an external source such as a job loss, divorce, or other loss affecting self-concept or self-esteem. Organic is not a type of crisis.

DIF: Cognitive Level: Application (Applying) REF: Pages: 400-401
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

5. While conducting the initial interview with a patient in crisis, the nurse should:
a. speak in short, concise sentences.
b. convey a sense of urgency to the patient.
c. be forthright about time limits of the interview.
d. let the patient know that the nurse is in control.
ANS: A
Severe anxiety narrows perceptions and concentration. By speaking in short, concise sentences, the nurse enables the patient to grasp what is being said. Conveying urgency will increase the patient’s anxiety. Letting the patient know who is in control and stating that time is limited are nontherapeutic strategies.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 404-405 | Pages: 407-409 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

6. An adult seeks counseling after the spouse is murdered. The adult angrily says, “I hate the beast that did this. It has ruined my life. During the trial, I don’t know what I’ll do if the jury doesn’t return a guilty verdict.” What is the nurse’s highest priority question?
a. “Would you like to talk to a psychiatrist about some medication to help you cope during the trial?”
b. “What resources do you need to help you cope with this situation?”
c. “Do you have enough support from your family and friends?”
d. “Are you having thoughts of hurting yourself or others?”
ANS: D
The highest nursing priority is safety. The nurse should assess suicidal and homicidal potentials. The incorrect options may be important but not the highest priority.

DIF: Cognitive Level: Application (Applying) REF: Pages: 403-405
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment

7. A woman says, “I can’t take anymore! Last year my husband had an affair and now we don’t communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she’s quitting college.” What type of crisis is this person experiencing?
a. Maturational
b. Adventitious
c. Situational
d. Recurring
ANS: C
A situational crisis arises from an external source and involves a loss of self-concept or self-esteem. An adventitious crisis is a crisis of disaster, such as a natural disaster or crime of violence. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists.

DIF: Cognitive Level: Application (Applying) REF: Page: 400
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

8. A woman says, “I can’t take anymore! Last year my husband had an affair and now we don’t communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she’s quitting college.” What is the nurse’s priority assessment?
a. Identifying measures useful to help improve the couple’s communication
b. Discussing the patient’s feelings about the possibility of having a mastectomy
c. Determining whether the husband is still engaged in an extramarital affair
d. Clarifying what the patient means by “I can’t take it anymore!”
ANS: D
During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the patient sought help.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 402-403
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

9. A woman says, “I can’t take anymore! Last year my husband had an affair and now we don’t communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she’s quitting college.” If this person’s immediate family is unable to provide sufficient situational support, the nurse should:
a. suggest hospitalization for a short period.
b. ask what other relatives or friends are available for support.
c. tell the patient, “You must be strong. Don’t let this crisis overwhelm you.”
d. foster insight by relating the present situation to earlier situations involving loss.
ANS: B
The assessment of situational supports should continue. Although the patient’s nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually nontherapeutic.

DIF: Cognitive Level: Application (Applying) REF: Pages: 402-403
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

10. A woman says, “I can’t take anymore! Last year my husband had an affair and now we don’t communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she’s quitting college and moving in with her boyfriend.” Which issue should be the focus for crisis intervention?
a. Possible mastectomy
b. Disordered family communication
c. Effects of the husband’s infidelity
d. Coping with the reaction to the daughter’s events
ANS: D
The focus of crisis intervention is on the most recent problem—“the straw that broke the camel’s back.” The patient has coped with the breast lesion, the husband’s infidelity, and the disordered communication. Disequilibrium occurs only with the introduction of the daughter leaving college and moving.

DIF: Cognitive Level: Application (Applying) REF: Page: 405
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

11. A patient visiting the crisis clinic for the first time asks, “How long will I be coming here?” The nurse’s reply should consider that the usual duration of crisis intervention is _______ weeks.
a. 1 to 2
b. 3 to 4
c. 4 to 6
d. 6 to 12
ANS: C
The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 6 weeks. If the crisis is not resolved by that time, the individual usually adopts dysfunctional behaviors that reduce anxiety without solving the problem. Crisis intervention can shorten the duration.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 399
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

12. An adult tells the nurse, “I can’t take anymore! Last year my husband had an affair and now we don’t communicate. Three months ago, I found a lump in my breast. Yesterday my daughter told me she’s quitting college and moving in with her boyfriend.” What is the priority nursing diagnosis?
a. Fear, related to impending breast surgery
b. Deficient knowledge, related to breast lesion
c. Ineffective coping, related to perceived loss of daughter
d. Impaired verbal communication, related to spousal estrangement
ANS: C
This nursing diagnosis is the priority because it reflects the precipitating event associated with the patient’s crisis. Data are not present to make the other diagnoses of Deficient knowledge, Fear, or Impaired verbal communication.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 403-404
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

13. Which communication technique is used more in crisis intervention than traditional counseling?
a. Role modeling
b. Giving direction
c. Information giving
d. Empathic listening
ANS: B
The nurse working in crisis intervention must be creative and flexible in looking at the patient’s situation and suggesting possible solutions to the patient. Giving direction is part of the active role a crisis intervention therapist takes. The other options are used equally in crisis intervention and traditional counseling roles.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 404-405
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

14. Which situation demonstrates the use of primary care related to crisis intervention?
a. Implementing suicide precautions for a patient with depression.
b. Teaching stress reduction techniques to a beginning student nurse.
c. Assessing coping strategies used by a patient who has attempted suicide.
d. Referring a patient with schizophrenia to a partial hospitalization program.
ANS: B
Primary crisis intervention promotes mental health and reduces mental illness. The incorrect options are examples of secondary or tertiary interventions.

DIF: Cognitive Level: Application (Applying) REF: Page: 405
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

15. A victim of spousal violence comes to the crisis center seeking help. The nurse uses crisis intervention strategies that focus on:
a. supporting emotional security and reestablishing equilibrium.
b. offering long-term resolution of issues precipitating the crisis.
c. promoting growth of the individual.
d. providing legal assistance.
ANS: A
Strategies of crisis intervention are directed toward the immediate cause of the crisis and are aimed at bolstering the emotional security and reestablishing equilibrium, rather than focusing on underlying issues and long-term resolutions. The goal is to return the individual to the pre-crisis level of function. Crisis intervention is, by definition, short term. Promoting growth is a focus of long-term therapy. Providing legal assistance might be applicable.

DIF: Cognitive Level: Application (Applying) REF: Page: 399 | Pages: 403-405
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

16. After celebrating a 40th birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred?
a. Reactive
b. Situational
c. Maturational
d. Adventitious
ANS: C
Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual, such as divorce and job loss. No classification called reactive crisis exists. Adventitious crises occur when disasters such as natural disasters (e.g., floods, hurricanes), war, or violent crimes disrupt coping styles.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 399-400
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

17. Which scenario is an example of an adventitious crisis?
a. Death of a child from sudden infant death syndrome
b. Being fired from a job because of company downsizing
c. Retirement of a 55-year-old
d. Riot at a rock concert
ANS: D
The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of situational or maturational crises.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 400-401
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

18. Which agency provides coordination in the event of a terrorist attack?
a. U.S. Food and Drug Administration (FDA)
b. Environmental Protection Agency (EPA)
c. National Incident Management System (NIMS)
d. Federal Emergency Management Agency (FEMA)
ANS: C
The NIMS provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 401
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment

19. During the initial interview at the crisis center, a patient says, “I’ve been served with divorce papers. I’m so upset and anxious that I can’t think clearly.” What could the nurse say to assess personal coping skills?
a. “What would you like us to do to help you feel more relaxed?”
b. “In the past, how did you handle difficult or stressful situations?”
c. “Do you think you deserve to have things like this happen to you?”
d. “I can see you are upset. You can rely on us to help you feel better.”
ANS: B
The correct answer is the only option that assesses coping skills. The incorrect options offer unrealistic reassurance, are concerned with self-esteem, and ask the patient to decide on treatment at a time when he or she “cannot think clearly.”

DIF: Cognitive Level: Application (Applying) REF: Pages: 402-405
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

20. An adult has cared for a debilitated parent for 10 years. The parent’s condition recently declined, and the health care provider recommended placement in a skilled care facility. The adult says, “I’ve always been able to care for my parents. Nursing home placement goes against everything I believe.” Successful resolution of this person’s crisis will most closely relate to:
a. resolving the feelings associated with the threat to the person’s self-concept.
b. maintaining the ability to identify situational supports in the community.
c. relying on the assistance from role models within the person’s culture.
d. mobilizing automatic relief behaviors by the person.
ANS: A
The patient’s crisis clearly relates to a loss of (or threatened change in) self-concept. Her capacity to care for her parents, regardless of the deteriorating condition, has been challenged. Crisis resolution involves coming to terms with the feelings associated with this loss. Identifying situational supports is relevant but less so than coming to terms with the threat to self-concept. Reliance on lessons from role models can be helpful but is not the primary factor associated with resolution in this case. Automatic relief behaviors are not helpful and are part of the fourth phase of crisis.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 399
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

21. The assumption most useful to a nurse planning crisis intervention for any patient is that the patient:
a. is experiencing a state of disequilibrium.
b. is experiencing a type of mental illness.
c. poses a threat of violence to others.
d. has a high potential for self-injury.
ANS: A
Disequilibrium is the only answer universally true for all patients in crisis. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness. The potential for self-violence or other-directed violence may or may not be a factor in crisis.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 399 | Page: 405
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

22. A nurse assesses an adult experiencing a crisis. An appropriate question for the nurse to ask to determine situational support is:
a. “Has anything upsetting occurred in the past few days?”
b. “Who can be helpful to you during this time?”
c. “How does this problem affect your life?”
d. “What led you to seek help at this time?”
ANS: B
Only the correct answer focuses on situational support. The incorrect options focus on the patient’s perception of the precipitating event.

DIF: Cognitive Level: Application (Applying) REF: Pages: 402-405
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

23. An adult comes to the crisis clinic after being terminated from a job of 15 years. The patient says, “I don’t know what to do. How can I get another job? Who will pay the bills? How will I feed my family?” Which nursing diagnosis applies?
a. Hopelessness
b. Powerlessness
c. Chronic low self-esteem
d. Disturbed thought processes
ANS: B
The patient describes feelings of the lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patient’s thought processes are not shown to be altered at this point.

DIF: Cognitive Level: Application (Applying) REF: Pages: 403-404
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

24. A troubled adolescent opened fire in a high school cafeteria, fatally shooting three people and injuring many others. Hundreds of parents come to the high school after hearing the news reports. After the police arrest the shooter, which action should occur next?
a. Ask the police to encircle the school campus with yellow tape to prevent parents from entering.
b. Announce over the loudspeakers, “The campus is now secure. Please return to your classrooms.”
c. Require parents to pass through metal detectors and then allow them to look for their children in the school.
d. Designate zones according to the alphabet, and direct students to the zones based on their surnames to facilitate reuniting them with their parents.
ANS: D
Chaos is likely among students and desperate parents. A directive approach is best. Once the scene is secure, creative solutions are needed. Creating zones by letters of the alphabet helps anxious parents and their children to unite. Preventing parents from uniting with their children would further incite the situation.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 400-401 | Page: 405
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

25. After completing the contracted number of visits to the crisis clinic, an adult says, “I’ve emerged from this as a stronger person. You supported me while I worked through my feelings of loss and helped me find community resources. I’m benefiting from a support group.” The nurse can evaluate the patient’s feelings about the care received as:
a. not at all satisfied.
b. somewhat satisfied.
c. moderately satisfied.
d. very satisfied.
ANS: D
The patient mentions a number of indicators that suggest a high degree of satisfaction with the Nursing Outcomes Classification of patient satisfaction: psychological care. No indicators express low-to-moderate satisfaction.

DIF: Cognitive Level: Application (Applying) REF: Pages: 403-404 | Page: 406
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care Environment

26. At the last contracted visit in the crisis intervention clinic, an adult says, “I’ve emerged from this a stronger person. You helped me feel like my life is back in balance.” The nurse responds, “I think it would be worthwhile to have two more sessions to explore why your reactions were so intense.” Which analysis applies?
a. The patient is experiencing transference.
b. The patient demonstrates a need for continuing support.
c. The nurse is having difficulty terminating the relationship.
d. The nurse is empathizing with the patient’s feelings of dependency.
ANS: C
The nurse’s remark is clearly an invitation to work on other problems and prolong contact with the patient. The focus of crisis intervention is on the problem that precipitated the crisis, not other issues. The scenario does not describe transference. The patient’s need for continuing support is not demonstrated in the scenario. The scenario does not describe dependency needs.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 404
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

27. Which health care worker should be referred to critical incident stress debriefing?
a. Nurse who works at an oncology clinic where patients receive chemotherapy
b. Case manager whose patients are seriously mentally ill and are being cared for at home
c. Health care employee who worked 8 hours at the information desk of an intensive care unit
d. Emergency medical technician (EMT) who treated victims of a car bombing at a department store
ANS: D
Although each of the individuals mentioned experiences job-related stress on a daily basis, the person most in need of critical incident stress debriefing is the EMT, who experienced an adventitious crisis event by responding to a bombing and provided care to victims of trauma.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 401 | Page: 406
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

1. A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would be expected from the driver immediately after this event? Select all that apply.
a. Difficulty using a cell phone
b. Long-term memory losses
c. Fecal incontinence
d. Rapid speech
e. Trembling
ANS: A, D, E
Immediate responses to crisis commonly include shock, numbness, denial, confusion, disorganization, difficulty with decision making, and physical symptoms such as nausea, vomiting, tremors, profuse sweating, and dizziness associated with anxiety. Incontinence and long-term memory losses would not be expected.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 402-403
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity