A nurse is assessing a client who has post-traumatic stress disorder. Which of the following findings should the nurse expect? (Select all that apply.)

Blames others for own mistakes

Has difficulty concentrating on set tasks

Difficulty falling or staying asleep

Holds persistent negative belief about self

Talks excessively

Answer and Explanation

Correct Answer : B,C,D

A.   Blaming others for one's own mistakes is not typically associated with PTSD. Individuals with PTSD may have heightened irritability or anger, but this does not necessarily translate to blaming others.
B.   Difficulty concentrating on tasks is a common symptom of PTSD as individuals may be easily distracted by intrusive thoughts related to their trauma.
C.   Difficulty falling or staying asleep is another symptom often reported by individuals with PTSD, which can be attributed to hyperarousal and intrusive thoughts.
D.   Holding persistent negative beliefs about oneself is indicative of the negative alterations in cognition and mood associated with PTSD.
E.   Talking excessively is not a common finding in PTSD. While some individuals may speak more when anxious, it is not a diagnostic criterion for PTSD.

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Correct Answer is A

Explanation

A. Documenting the client's behavior every 15 minutes is essential for monitoring the client's condition, response to seclusion, and any changes in behavior or status.
B. Obtaining the provider's prescription within 60 minutes may be necessary but does not address immediate nursing actions required after placing the client in seclusion.
C. Monitoring vital signs every 4 hours is not specific to managing a client in seclusion and may not provide timely information about the client's condition or response to seclusion.
D. Offering food and fluids every 2 hours is important for meeting the client's physiological needs but may not be appropriate immediately after placing the client in seclusion, depending on the circumstances and facility policies.

A. Offer to talk with the caregiver about their feelings. B. Refer the caregiver to a local support group. C. Discuss relaxation techniques with the caregiver. D. Consult social services to explore counseling for the caregiver.

Correct Answer is A

Explanation

A. Offering to talk with the caregiver about their feelings provides immediate support and validation of their emotions. It allows the caregiver to express their concerns and stressors, which can help alleviate some of the caregiver's distress.
B. Referring the caregiver to a local support group is a helpful intervention but may not address the caregiver's immediate emotional needs. Offering immediate support by listening and empathizing is the first step.

C. Discussing relaxation techniques with the caregiver may be beneficial, but addressing the caregiver's emotional distress should take precedence.
D. Consulting social services to explore counseling for the caregiver is a valuable intervention, but offering immediate support by engaging in a conversation about their feelings is the most appropriate initial action.

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A nurse is assessing a client who has post-traumatic stress disorder. Which of the following findings should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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