A nurse is caring for a client who has been diagnosed with acute stress disorder. Which of the following client statements aligns with this diagnosis?

“I was in a car crash two weeks ago and I have nightmares when I sleep.”.

“I was physically abused as a child and have frequent flashbacks since then.”.

“I was in a terrible car crash two years ago and I have been unable to drive since then.”.

“My parents fought a lot when I was a child.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Acute Stress Disorder (ASD) is a mental health condition that can occur in the immediate aftermath of a traumatic event, with symptoms starting within four weeks of the event and lasting for a minimum of three days and up to one month. This client’s statement about experiencing nightmares following a car crash two weeks ago aligns with the diagnosis of ASD.

Nightmares are a common symptom of ASD, often replaying the traumatic event, leading to disrupted sleep and increased distress.
Choice B rationale
This statement is more indicative of Post-Traumatic Stress Disorder (PTSD), a related but distinct condition from ASD. PTSD is characterized by persistent and intrusive memories of the traumatic event, which can include flashbacks, and symptoms must last for more than a month and cause significant distress or functional impairment. The chronic nature of the symptoms described by the client, including frequent flashbacks since childhood, is more consistent with PTSD than ASD.
Choice C rationale
This statement could suggest a condition known as Specific Phobia, Situational Type. This is a type of anxiety disorder characterized by an intense, persistent fear of certain situations. The individual will avoid the situation or endure it with intense fear or anxiety. In this case, the client’s inability to drive following a car crash two years ago could indicate a specific phobia related to driving.
Choice D rationale
The experience described by the client in this statement is indicative of a dissociative symptom, which can be a feature of several different mental health disorders, including but not limited to Dissociative Disorders and PTSD1. The feeling of leaving one’s body is referred to as depersonalization, a type of dissociation that can occur as a response to trauma. However, without more information, it is difficult to align this statement with a specific diag

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Correct Answer is B

Explanation

Choice A rationale
Including the opinions of other team members in the documentation may introduce bias and is not a best practice for ensuring competency in documentation.
Choice B rationale
Including the client’s own words when describing what happened is a best practice in documentation. It ensures accuracy and allows for an objective record of the incident.
Choice C rationale
Describing what happened subjectively may introduce personal bias into the documentation and is not a best practice for ensuring competency in documentation.
Choice D rationale
Providing general and broad details may not accurately capture the incident. Specific, factual, and detailed documentation is a best practice.

A. The nurse maintained an upright posture. B. The nurse sat at a slight angle across from the clients. C. The nurse maintained eye contact throughout the interview. D. The nurse leaned away from the client throughout the interview.

Correct Answer is D

Explanation

Choice A rationale
Maintaining an upright posture during a client interview is generally seen as a sign of attentiveness and professionalism. It shows that the nurse is focused on the conversation and respects the client’s concerns.
Choice B rationale
Sitting at a slight angle across from the clients is a part of active listening and is considered a positive nonverbal communication technique. It allows the nurse to maintain eye contact and observe the client’s nonverbal cues.

Choice C rationale
Maintaining eye contact throughout the interview is a positive nonverbal communication technique that shows the nurse is paying attention and is interested in what the client is saying. However, it’s important to note that in some cultures, direct eye contact may be considered disrespectful or intrusive.
Choice D rationale
Leaning away from the client throughout the interview can be perceived as a sign of disinterest or discomfort. It may give the impression that the nurse is not engaged in the conversation or is maintaining a distance from the client. This can hinder the development of a therapeutic nurse-client relationship.

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A nurse is caring for a client who has been diagnosed with acute stress disorder. Which of the following client statements aligns with this diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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