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 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.

A. Instruct the client to consume a low-sodium diet to decrease hand tremors. B. Teach the client to take the lithium in a single daily dose C. Contact the provider for a possible decrease in the lithium dosage. D. Encourage the client to take naproxen sodium to decrease tremors.

Correct Answer is C

Explanation

A. Instruct the client to consume a low-sodium diet to decrease hand tremors:
While maintaining a stable sodium intake is important for individuals taking lithium to avoid fluctuations in lithium levels, a low-sodium diet is not specifically indicated to address hand tremors caused by lithium. Adjusting sodium levels is more about maintaining a consistent intake to stabilize lithium levels over time.

B. Teach the client to take the lithium in a single daily dose:
Lithium is often prescribed in divided doses to maintain stable blood levels throughout the day and minimize side effects. However, the dosing regimen (once or multiple times a day) is usually determined by the healthcare provider based on the individual's needs. Changing the dosing frequency is not the primary intervention for managing hand tremors.

C. Contact the provider for a possible decrease in the lithium dosage:
Hand tremors are a common side effect of lithium. If a client is experiencing bothersome side effects within the therapeutic range, the appropriate action is to contact the healthcare provider. The provider can assess the situation, possibly adjust the dosage, or explore other management options to alleviate the tremors while maintaining the therapeutic effect of the medication.

D. Encourage the client to take naproxen sodium to decrease tremors:
Encouraging the client to take naproxen sodium or any other nonsteroidal anti-inflammatory drug (NSAID) is not recommended when the client is on lithium therapy. NSAIDs can interact with lithium, potentially leading to increased lithium levels and toxicity. Combining these medications should be avoided.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health clinic is reviewing laboratory results for a client who has a prescription for risperidone. For which of the following findings should the nurse notify the provider?

Correct Answer is D

Explanation

A nurse in a community mental health clinic is assessing a client who began taking lithium carbonate 5 days ago. The client reports fine hand tremors and has a current lithium level of 1.2 mEq/L. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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