In caring for the patient’s spiritual needs, the nurse asks 20 questions to assess the patient’s relationship with God and a sense of life purpose and satisfaction. Which method is the nurse using?

Choice A reason: Acute stress disorder occurs within one month of trauma, with symptoms like nightmares and dissociation. However, symptoms persisting beyond one month, as in this case, indicate PTSD. The patient’s presentation aligns with chronic trauma effects, making PTSD the more likely diagnosis over acute stress disorder.

Choice B reason: General adaptation syndrome describes the body’s physiological response to stress (alarm, resistance, exhaustion). It is not a psychiatric diagnosis and does not account for trauma-specific symptoms like nightmares or emotional numbing. This is unrelated to the patient’s psychological response, making it incorrect.

Choice C reason: PTSD is characterized by persistent symptoms beyond one month post-trauma, including nightmares, intrusive memories, avoidance, and emotional numbing, matching the patient’s presentation. Sexual assault is a common trigger, and the nurse would expect this diagnosis documented due to the chronicity and specificity of symptoms.

Choice D reason: Alarm reaction is the initial phase of general adaptation syndrome, involving acute stress response like fight-or-flight. It is not a diagnosis and does not explain chronic psychological symptoms like recurrent memories or emotional detachment, making it irrelevant to the patient’s trauma-related condition.

Choice A reason: Immediate intubation is premature without first reversing opioid-induced respiratory depression with naloxone. Morphine’s rapid onset of lethargy and shallow breathing (7 breaths/min) indicates overdose, reversible by naloxone. Intubation is invasive and reserved for non-responsive cases, risking unnecessary complications when reversal is feasible, delaying targeted treatment in this acute scenario.

Choice B reason: Administering naloxone is the priority for opioid overdose, as evidenced by lethargy and respiratory depression (7 breaths/min) post-morphine. Naloxone, an opioid antagonist, rapidly reverses these life-threatening effects, restoring breathing and consciousness. Prompt administration is critical in older adults, who are more sensitive to opioids, ensuring patient safety and preventing hypoxia or death.

Choice C reason: Observing for opioid tolerance is inappropriate in this acute situation. Lethargy and shallow breathing indicate overdose, not tolerance, requiring immediate naloxone. Monitoring tolerance delays critical intervention, risking prolonged hypoxia, brain damage, or death, especially in an elderly patient with increased opioid sensitivity post-surgery, where respiratory depression is life-threatening.

Choice D reason: Assessing pain level is irrelevant when the patient exhibits opioid overdose symptoms like lethargy and respiratory depression. Pain assessment is secondary to reversing life-threatening respiratory compromise with naloxone. Delaying intervention for pain evaluation risks patient deterioration, as immediate action is needed to restore breathing and stabilize the patient post-morphine administration.