List at least five actions the nurse should take 1. 2. 3. 4. 5. 6. 7.

Assess the client for any type of past or ongoing abuse. Attend to the clients needs and concerns in a nonjudgmental manner Reassure the client of her safety while at the emergency department and assure her of her privacy Protect the clients confidentiality Encourage the client to talk about issues and concerns Assess for feelings of depression, helplessness, self-blame, and fear. Assess for existing social support.

Type possible abuse Maria may experiences: Maria may be experiencing financial exploitation and neglect. Abuse indicator: a) Disheveled, with poor hygiene, underweight, and dehydrated b) Glasses and hearing aids have been missing since last year and no one has been able to find them c) Son in law is getting drunk almost every night and verbally abuses her daughter and the children. d) Jewelry and money are missing e) Alone at home when the family take trips f) Feels unwelcome and afraid that no one will help her. 3. List areas that require further exploration a) Clients lost glasses and hearing aids b) Clients dehydration and low weight c) Substance abuse of the son-in-law and its effect on the family d) Clients missing money and jewelry. 4. What mental health issues is Maria facing? a) Loss of husband b) Loss of her independence c) Depression d) Possible abuse 5. List at list four steps the nurse should take to address the clients needs. a) Initiate trust-building relationship b) Listen attentively, respond to clients concerns c) Exhibit consistent and genuine behavior. d) Give client time to respond to questions e) Offer support, acknowledgment feelings f) Provide anticipatory guidance. g) Identify and suggest Community support services for the client and the family.
Karmella: The therapist may ask her to keep a journal, noting what is happening right before her panic attacks begin. Also, may discuss healthy coping, such as asking for help and caring for herself when unable to do this. Also, suggest to attend a support group after discharge for sexual trauma victim. -Discuss the development of mental health problem following a natural disaster or terrorism -Outline the process for assessing trauma reactions in individuals across the life span. -Use the nursing process to develop a comprehensive plan of care or addressing recovery from a natural disaster or terrorism. 2. What should be included in the client education and intervention to help heal? a) b) c) d) Karmella should be educated on the relationship between her anxiety symptoms, her panic attacks, and the rape. Be encouraged to continue writing in her journal, keeping a record of her panic attacks and their frequencies. Continue with support group. Discuss with her possibility of group cognitive therapy, which is beneficial for pstd patient.

Alzheimer pt 1. 1. Safety is a priority, so wandering will have to be addressed first. 2. Also need to be evaluation of how to identify when the clients safety exceed the care the daughter and her family can provide. 2. Family has asked for help in improving communication with the client, guidelines to discuss: a) b) c) Explain to the family that aphasia, agnosia and confabulation are common symptoms of alzheimers type. The verbale communication decreased, his non verbal communication become more important. Tell the family to call the client by name and give simple direction.

3. The daughter states that client wanders from room to room, Intervention for wandering: a) Tell the family to stay with the client to be sure the client is in a safe enclosed area. Tell the family to maintain a calm demeanor and approach the client slowly and give him space. Help the family determine why the client is wandering. 4. The family has asked for help in managing the increased confusion and agitation, measures to suggest: a) Instruct the family to avoid leaving the client alone or in isolated room without some stimulation, to support reality testing b) The room should be well-lit and without shadow or glare. c) If client becomes combative, intervene to redirect and prevent harm to self and others d) attempt to distract, reassuring the client, You are in a safe place