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":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Blood pressure Potential worsening: The blood pressure dropped from 114/64 mm Hg on Day 1 to 98/56 mm Hg on Day 2, indicating a potential worsening as it decreased.

Gait when ambulating - Potential worsening: The client's gait was noted to be uncoordinated when ambulating to the bathroom on Day 2, suggesting a potential worsening in motor coordination or balance.

Lithium level Potential worsening: The lithium level increased from 1.9 mEq/L on Day 2, exceeding the therapeutic range (less than 1.5 mEq/L), indicating a potential worsening due to lithium toxicity.

Urine amount and color - Potential worsening: polyuria is a sign of lithium toxicity.

Blurred vision Potential worsening: The client reports blurred vision and frequently rubs their eyes on Day 2, indicating a potential worsening of visual acuity or ocular health.

A. Ask the provider to renew the prescription every 8 hr. B. Have a staff member check on the client every 30 min. C. Assess the client's need for toileting every 15 min. D. Offer hydration and nutrition to the client every 2 hr.

Correct Answer is D

Explanation

A. The provider must renew the prescription for restraints every 4 hours for adults, not every 8 hours.
B. A staff member should check on the client every 15 minutes, not every 30 minutes, to ensure safety.
C. The client should be assessed for toileting needs every 2 hours, not every 15 minutes.
D. Offering hydration and nutrition every 2 hours is appropriate to maintain the client’s basic needs while in restraints.

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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.)

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A nurse is caring for an adult client who has been placed in physical restraints due to aggressive behavior. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

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