A nurse is caring for a client:

The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all." In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

Click to highlight the areas that the nurse should react to immediately. The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all" In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

she only gets 2 to 3 hours of sleep

She feels that she is "jumpy" after the accident

I feel so sad that I can't seem to feel anything at all"

The client has returned to work at an accounting firm

Answer and Explanation

The Correct Answer is ["A","B","C"]

In the scenario presented, the nurse should prioritize addressing the client's sleep disturbances, heightened startle response, and feelings of sadness and numbness. These symptoms may indicate acute stress reaction or post-traumatic stress disorder, conditions that can occur after experiencing a traumatic event such as a car crash. Immediate interventions could include providing a safe and calm environment, offering support and reassurance, assessing for risk of harm to self or others, and referring to mental health professionals for further evaluation and treatment. It's also important to acknowledge the client's proactive steps, such as joining a grief support group and exercising, which are positive coping strategies. The nurse should collaborate with the client to build on these healthy habits while addressing the more distressing symptoms with appropriate care and referrals.

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

Explanation

Numbness: Rape-trauma syndrome: Numbness can be a symptom of the acute phase of rape trauma syndrome, where individuals may experience emotional detachment or a sense of being emotionally overwhelmed.
- Poor decision making: Alcohol intoxication: Poor decision making is a common symptom of alcohol intoxication due to impaired judgment and cognitive function caused by alcohol consumption.
- Crying: occurs in both alcohol intoxication and rape-trauma syndrome. Crying is a common emotional response during the acute phase of rape-trauma syndrome as individuals may experience intense feelings of sadness, fear, or helplessness. Crying may also occur in individuals experiencing alcohol intoxication, especially if they become emotionally overwhelmed or as a result of disinhibition caused by alcohol consumption. - Disbelief: Disbelief or denial is a typical reaction in the acute phase of rape-trauma syndrome as individuals may struggle to come to terms with the reality of the traumatic event. - Irritability: Irritability can result from alcohol intoxication due to its effects on mood regulation and inhibition.
- Difficulty concentrating: Difficulty concentrating is a common symptom of alcohol intoxication due to its sedative effects on cognitive function. Individuals in the acute phase of rape-trauma syndrome may also experience difficulty concentrating as a result of heightened emotional arousal and intrusive thoughts related to the traumatic event.

A. "I understand that you're angry and unhappy. Let's explore ways in which you overreact." B. "I hear your frustration about losing control. Tell me how this affects your daily life." C. "Knowing the cause of your symptoms will make them easier to handle." D. "Do all that you can to learn all that you can while you are here. You can get better."

Correct Answer is B

Explanation

A. This comment may come across as invalidating the client's feelings by assuming overreaction, which could potentially escalate the situation.
B. This response acknowledges the client's feelings and invites further exploration, fostering a therapeutic relationship and understanding of the client's experiences.
C. While understanding the cause of symptoms is important, it may not necessarily make them easier to handle, and it could divert focus from addressing the client's immediate concerns.
D. While encouragement is positive, this comment does not directly address the client's feelings or concerns, which is essential for building a therapeutic relationship.

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Naxlex Comprehensive Predictor Exams

Mark which behaviors might be related to alcohol intoxication, acute phase of rape- trauma syndrome, or both. Tick only 1 box.

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

Explanation

A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?

Correct Answer is B

Explanation

The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?

A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?