A nurse is admitting a client who has posttraumatic stress disorder (PTSD) to a community mental health facility. Which of the following manifestations should the nurse expect when completing the admission assessment?
Decreased startle response to loud noises.
Reports uninterrupted sleep of 10 to 12 hours each night.
Reluctance to discuss the event that precipitated the distress.
Reports feelings of acute distress that began 1 to 2 weeks ago.
The Correct Answer is C
A reason: Decreased startle response to loud noises. Clients with PTSD typically have an increased startle response due to hyperarousal. A decreased startle response would not be expected in PTSD.
B reason: Reports uninterrupted sleep of 10 to 12 hours each night. Clients with PTSD often experience sleep disturbances, including nightmares and insomnia. Reporting uninterrupted sleep is not characteristic of PTSD.
C reason: Reluctance to discuss the event that precipitated the distress. Clients with PTSD commonly avoid discussing the traumatic event as a way to avoid triggering distressing memories and emotions. This avoidance behavior is a key symptom of PTSD.
D reason: Reports feelings of acute distress that began 1 to 2 weeks ago. PTSD symptoms usually develop within three months of the traumatic event but can also emerge years later. Acute distress that began 1 to 2 weeks ago may not align with the typical onset pattern of PTSD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A reason: Encourage the client to attend group therapy sessions. While group therapy can be beneficial for some clients, it may not be the best initial approach for those with panic disorder. Group settings can sometimes increase anxiety and trigger panic attacks.
B reason: Allow the client to choose scheduled daily activities. While allowing clients some control over their daily activities can be empowering, it does not directly address the symptoms of panic disorder. Structured interventions and therapeutic techniques are more effective.
C reason: Use simple words to describe procedures to the client. Using simple, clear language when explaining procedures helps reduce anxiety and prevent misunderstandings that could trigger a panic attack. This approach is particularly effective for clients with panic disorder, who may become easily overwhelmed.
D reason: Avoid discussing topics that can trigger a panic attack. While it is important to be mindful of topics that may cause distress, complete avoidance can prevent clients from learning to manage their triggers. Therapeutic approaches often involve gradual exposure to triggers in a controlled and supportive environment.
Correct Answer is D
Explanation
A reason: "I agree with you. I'm sure this will never happen again." Agreeing with the parent without further investigation is inappropriate and does not address the potential risk to the child. The nurse should gather more information to assess the situation fully.
B reason: "This is awful. You should file charges against your partner." Suggesting that the parent file charges is premature without understanding the full context of the situation. The nurse's role is to gather information, assess the risk, and take appropriate protective actions.
C reason: "This is clearly child endangerment. I will have to call the police." While the nurse has a responsibility to report suspected child abuse, it is important to gather more information first. This response could escalate the situation without a thorough assessment.
D reason: "I'd like to know more about what happened. Let's sit and talk." This response is appropriate as it allows the nurse to gather more information about the situation in a non-confrontational manner. It helps build rapport with the parent while assessing the child's safety.
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