A nurse is assessing a client who experienced a sexual assault. Which of the following findings should the nurse identify as an indication the client might be experiencing posttraumatic stress disorder?

Increased time sleeping

Inability to express empathy

Auditory hallucinations

Difficulty concentrating

Answer and Explanation

The Correct Answer is D

A. Increased time sleeping:
Increased time sleeping alone is not a specific or direct indicator of PTSD. However, changes in sleep patterns are common in individuals with PTSD, with symptoms like nightmares, insomnia, and disturbances in sleep. These disturbances can lead to increased time in bed, but this alone is not a definitive sign of PTSD.

B. Inability to express empathy:
Inability to express empathy is a complex issue and could be related to various emotional or psychological factors. While people with PTSD can experience difficulties in interpersonal relationships, including issues with empathy, this alone is not a specific indicator of the disorder. PTSD primarily involves symptoms related to re-experiencing trauma, avoidance, negative mood changes, and arousal symptoms.
C. Auditory hallucinations:
Auditory hallucinations, which involve hearing voices or sounds that others do not, are not typically associated with PTSD. This symptom is more commonly linked to conditions like schizophrenia or other psychotic disorders, but it is not specific to PTSD.

D. Difficulty concentrating:
Difficulty concentrating is a common and well-recognized symptom of PTSD. Individuals with PTSD often struggle with focus, memory, and attention due to the intrusion of traumatic thoughts and memories. This symptom can significantly impact their daily functioning and is one of the hallmark features of the disorder.

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Correct Answer is A

Explanation

A. Implement measures to prevent intentional self-inflicted injury:
This choice is the priority. Individuals with borderline personality disorder are at an increased risk of self-harm and suicidal behaviors. Implementing measures to prevent intentional self-inflicted injury, such as close monitoring, removing potentially harmful objects, and creating a safe environment, is crucial to ensuring the client's safety and well-being.

B. Discuss the appropriate use of assertive behavior with the client:
Teaching assertive behavior is an important aspect of therapy for individuals with borderline personality disorder. Learning to express emotions and needs in a healthy, assertive manner can improve their interpersonal skills and relationships. However, this choice is secondary to ensuring the client's safety. Safety concerns need to be addressed before moving on to other therapeutic interventions.

C. Encourage the client to attend weekly support group meetings:
Support group meetings can provide valuable social support and a sense of belonging for individuals with borderline personality disorder. Being part of a supportive community can offer understanding and coping strategies. While this is a beneficial intervention, it is not the priority. Safety concerns and addressing self-harm risk take precedence.

D. Assist the client to maintain awareness of her thoughts and feelings:
Developing self-awareness and emotional regulation skills is essential in managing borderline personality disorder. Techniques such as mindfulness and dialectical behavior therapy (DBT) can help individuals become more aware of their thoughts and emotions. While important for long-term management, this intervention is not the priority when immediate safety concerns are present. Safety should always be the first focus of care.

A. Aspartate aminotransferase 20 units/L B. Platelets 250.000/mm3 C. Sodium 140 mEq/L D. Fasting glucose 175 mg/dL

Correct Answer is D

Explanation

A. Aspartate aminotransferase 20 units/L:
This result indicates the level of an enzyme in the blood. A value of 20 units/L is within the normal range (usually 10-40 units/L). Aspartate aminotransferase (AST) is an enzyme found in the liver, heart, muscles, and other tissues. Elevated levels might indicate liver damage, but 20 units/L is a normal value.

B. Platelets 250,000/mm3:
Platelets are components of blood that help with clotting. A value of 250,000/mm3 is within the normal range (normal range is typically 150,000 to 450,000/mm3). Normal platelet levels are crucial for preventing excessive bleeding or clotting.

C. Sodium 140 mEq/L:
Sodium is an electrolyte essential for maintaining the body's water balance and nerve function. A level of 140 mEq/L falls within the normal range (typically 135-145 mEq/L). Proper sodium levels are important for overall body functioning.

D. Fasting glucose 175 mg/dL:
This indicates the concentration of glucose (sugar) in the blood after a period of fasting. A level of 175 mg/dL is elevated. Fasting glucose levels above 125 mg/dL may suggest diabetes or prediabetes. Elevated glucose levels are a cause for concern as they indicate poor blood sugar regulation, which can lead to various health complications, including diabetes.

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A nurse is assessing a client who experienced a sexual assault. Which of the following findings should the nurse identify as an indication the client might be experiencing posttraumatic stress disorder?

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Correct Answer is D

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