A 28-year-old client is admitted to the psychiatric unit following a motor vehicle accident. The client reports experiencing recurrent flashbacks, intrusive thoughts, and hypervigilance. The nurse suspects the client is experiencing symptoms of PTSD. Which assessment finding further supports this suspicion?

Binge eating and weight gain

Nightmares, difficulty concentrating, and irritability

Purging the last meal

Decreased energy and fatigue

Answer and Explanation

The Correct Answer is B

A. Binge eating and weight gain are more commonly associated with eating disorders or other psychological conditions, not PTSD.

B. Nightmares, difficulty concentrating, and irritability are key symptoms of PTSD, reflecting the psychological impact of trauma. These are consistent with the intrusive and arousal symptoms associated with PTSD.

C. Purging is associated with eating disorders, not PTSD.

D. Decreased energy and fatigue are common symptoms of depression, not specifically indicative of PTSD, although they can be seen in both conditions.

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Correct Answer is B

Explanation

A. Chills are not a common symptom of moderate anxiety; they are more likely to occur with fever or cold exposure.

B. Anxiety often leads to physical symptoms such as urinary frequency due to increased sympathetic nervous system activity.

C. Rapid speech can occur with anxiety, but it is more commonly seen in severe anxiety, not moderate anxiety.

D. A distorted perceptual field is more typical of severe anxiety or panic attacks, not moderate anxiety.

A. Refer the client to a support group for individuals with PTSD B. Encourage the client to practice mindfulness meditation C. Provide a structured environment with predictable routines, and consistent staff D. Administer a PRN sedative medication as needed

Correct Answer is C

Explanation

A. While support groups may be helpful, the immediate intervention for a client experiencing heightened anxiety and hypervigilance is to provide structure and safety.

B. Mindfulness meditation may be beneficial in the long term, but it is not the first intervention in an acute phase where anxiety and hypervigilance are prominent.

C. A structured environment with predictable routines and consistent staff can help clients with PTSD feel more secure and reduce feelings of anxiety, hypervigilance, and paranoia. Predictability and structure are key interventions for clients with PTSD.

D. Administering a PRN sedative medication should be a secondary intervention after providing a supportive and safe environment. Medications may be used as part of treatment, but they do not address the underlying anxiety and hypervigilance as effectively as a structured environment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A client with PTSD experiences exaggerated startle response. The client is paranoid and hypervigilant. Which nursing intervention is most appropriate?

Correct Answer is C

Explanation

A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, "I don't know why my wife left me." The client receives a diagnosis of anxiety. The nurse realizes the client's findings support which level of anxiety?

A nurse is preparing to administer lithium 300 mg PO every 8 hr. Available is lithium carbonate 150 mg capsules. How many capsules should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?

A nurse reviews the laboratory report for a client who is receiving lithium three times daily PO. The client's current blood lithium level is 1.8 mEq/L. The nurse identifies that this lab value indicates which of the following?

A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?

A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and ataxia. Which of the following actions should the nurse take?

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