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Emma Jackson, a 1-year widow who lost her job 3 months ago

Emma Jackson, a 1-year widow who lost her job 3 months ago, has spent 2 days in a row, from morning till time to pick up her kids at the school bus stop, waiting in an emergency department to get help for what appears to be severe depression.

Now, at the end of this second day sitting in the waiting area, she approaches the admitting nurses’ station in tears and says, “I don’t know how much longer I can take this. Don’t you recognize me?”

“No, ma’am, I’m sorry,” the nurse says. “Offhand, I don’t.”

“Well,” says Emma, “I’ve come in here 2 days in a row. I need help, and I can’t get in to see anybody because I’m not bleeding to death, but I’m desperate! I’ve spent the last 2 weeks, until yesterday, in bed. And yet I can’t sleep. Do you know how many days I’ve been without sleep? I’m so exhausted and so depressed I’m tempted to shake my kids for the least little thing, and I now have zero tolerance for careless drivers and sometimes I just want to drive straight into them to teach them a lesson, and that’s not like me. My kids are becoming my only reason for going on, and that’s not good for them. I think they can see it, and it scares them. They’re trying to be super-good …”

Thinking of how her despair is affecting her children, Emma bursts into uncontrollable sobs.


1. The psychiatric nurse takes Emma into an examining room immediately to interview her. Based only on what you’ve just read, what in your opinion is the likelihood of Emma being admitted for short-term inpatient care? Give at least two admission criteria that may apply to her situation. Offer (a) a possible causative factor and (b) symptomatic evidence.2. Further assessments lead the psychiatric mental health team to recommend that Emma agree to a 72-hour inpatient visit to stabilize her current condition. The team would work with her to

ensure that her and her children’s needs are being met and to explore ongoing treatment options as well as social, psychiatric, and other services. Emma agrees and arranges for a church member to keep her children during that time.

Later that night, though, she changes her mind and approaches the night nursing staff about checking herself out. The nurse on duty discourages her; when Emma then asks to take her cell phone back to her room to call her brother, the nurse says, “Why don’t you stay here at the station while you make your call.”

Emma becomes very angry and anxious, so the nurse isn’t sure if she should hand her the phone in that condition. The nurse tries to give her an oral sedative to help her calm down awhile before making her call, but Emma pushes it angrily away and says, “I’m not leaving this spot until I can talk to my brother!”

What should the nurse do in this situation? What recourse does she have when this patient will not comply with requests and, more significantly, refuses her medication?








Mr. and Mrs. Ebrahimi are refugees from a Middle Eastern nation torn by a severe internal conflict. They arrived in this country 3 years ago, along with their two daughters, who were 11 and 14 years old. During that time, they have worked hard with an international agency to gradually get Mr. Ebrahimi’s aging uncle out of a refugee camp and into the United States. His uncle has now been living with the family for the past 3 months.

Life for the Ebrahimis has been difficult, to say the least; coming to the United States has not solved their problems. Although they feel safer, their youngest child, Dorri, and her great-uncle both have trouble sleeping. “I wake up sometimes,” Dorri says, “and I think I hear people shouting and running in our yard, but there’s no one there.” Her great-uncle exhibits signs of posttraumatic stress, but refuses to talk about it, even to his nephew.

There have been other challenges as well. The girls, Dorriand TalAyeh, quickly adapted to American customs and language in their school, where they were readily accepted. Now, 3 years later, TalAyeh, who is very talented, is applying to music schools and has won two scholarships in voice. This is causing escalated arguments with her parents.

“You should be proud of me for winning scholarships,” she says.

“We will be proud when you do what you’re supposed to do,” her father tells her, “and go to medical school like your mother. This is tradition.”

Mrs. Ebrahimi looked forward to returning to her profession as a pediatrician and was stunned to find that her credentials could not be accommodated without going back to school for a significant length of time—something that the family has still not been able to afford, even 3 years later.

Despite the urgency of removing his family to safety, Mr. Ebrahimi was always worried about entering Western culture. “I knew morals would be incorrect here,” he says, “and I was right. My children are losing their values, and there are no morals at work either.” When asked to explain, he describes how he recently lost his job “because my uncle fell and broke his leg while trying to clean a window.”

“Of course, I could not show up for work for weeks. My uncle had a broken leg! He developed an infection in recovery! I came and went to work now and then as I could, but everyone knows my first duty was to make my old uncle comfortable. What kind of boss wouldn’t understand that?”

“Nobody understands that Dad,” TalAyeh says sympathetically. “Not here.”


1. This case study indicates that the Ebrahimi family were refugees. What evidence do you see that this might be creating special problems that may not occur in the larger immigrant population?2. 2. How have different rates of acculturation and assimilation affected these family members?









Evan is a psychiatric nurse working on an inpatient floor in a general community hospital. Mr. Girardi has been in a car accident, which has landed both him and his daughter in critical care. Because of Mr. Girardi’s extensive injuries, his physicians prescribe that he be put on light sedatives that do not induce coma but keep him sleepy and calm. They simultaneously decide not to immediately inform him of his daughter’s critical condition. The rationale for both decisions is their concern that he not cry, which would cause extended damage to his perforated lung. Mr. Girardi is kept drowsy and motionless and as pain-free as possible. He has asked about his daughter, but when told that the staff will check on her, he is satisfied with that and drifts back to sleep.

​Mr. Girardi’s wife arrives to stay with him. It is 3:18 AM, and Evan has just administered Mr. Girardi a sedative through his IV set. Mrs. Girardi tells Evan that her husband took his last “kidney stone pill” at 6 PM with his dinner before he and his daughter left the house. “He’s overdue for that kidney stone pill,” Mrs. Girardi says. “He’s not supposed to skip that.”

​Evan says, “He shouldn’t take anything else right now, but I’ll check that out.” She assures Mrs. Girardi that she’ll ask the doctor about that and leaves the room.

​Fifteen minutes later, Evan returns, explaining that she consulted with the hospital surgeon, who checked with Mr. Girardi’s urologist. The urologist confirmed that the “kidney stone pill” was a painkiller, which, under the circumstances, should be discontinued as long as Mr. Girardi is on the more powerful IV sedatives.

​”Oh, that’s okay,” Mrs. Girardi tells Evan. “He woke up a bit while you were gone, and I was able to give him his pills.”

​Mr. Girardi suffers moderate complications from the IV sedative and oral analgesic combination, which extends his hospital stay by 2 days. The Girardis feel that the hospital should have been in better control of the overdose, saying that if the staff had been on top of things and supervising more closely, this would not have happened.


1. In the case of Mr. Girardi, do you think this case is most concerned with cause in fact, proximate cause, or foreseeability of harm?