A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

"My child was born with a birth defect due to an exposure I had overseas."

I check any room I enter because the enemy is still after me and could be hiding anywhere."

"In my dreams, all I can see are the wounded reaching out and trying to grab me."

"I killed four enemy soldiers with my bare hands and saved my entire battalion."

Answer and Explanation

The Correct Answer is C

A) "My child was born with a birth defect due to an exposure I had overseas."

This statement does not directly relate to the core symptoms of PTSD. While exposure to trauma can have a variety of consequences, including potential exposure-related health issues, this statement does not necessarily indicate the re-experiencing, avoidance, or hyperarousal symptoms characteristic of PTSD.

B) "I check any room I enter because the enemy is still after me and could be hiding anywhere."

This statement is more indicative of hyperarousal and hypervigilance, which are common symptoms of PTSD. However, it does not explicitly involve re-experiencing the traumatic event through nightmares or intrusive memories, as described in the correct answer.

C) "In my dreams, all I can see are the wounded reaching out and trying to grab me."

Explanation:

The statement "In my dreams, all I can see are the wounded reaching out and trying to grab me" indicates symptoms commonly associated with posttraumatic stress disorder (PTSD). This statement reflects the re-experiencing symptom cluster of PTSD, where individuals may have distressing and intrusive memories, nightmares, or flashbacks related to the traumatic event they experienced. The imagery of wounded individuals trying to grab the person suggests a strong emotional impact and ongoing distress related to the traumatic experience.

D) "I killed four enemy soldiers with my bare hands and saved my entire battalion."

While this statement might reflect exposure to a traumatic event and could contribute to symptoms of PTSD, it is presented in a way that seems more like a narrative of heroic actions rather than a symptom of distress or re-experiencing.

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Correct Answer is C

Explanation

A. "You are being unreasonable, and I will not call your doctor at this hour."

This response is confrontational and dismissive of the client's request. It does not promote a therapeutic interaction and might escalate the situation.

B. "Go back to your room, and I'll try to get in touch with your doctor."

This response might temporarily calm the client, but it’s misleading if the nurse does not intend to call the doctor. It also avoids addressing the client's immediate emotional needs and could result in a loss of trust if the nurse doesn’t follow through.

C. "You must be very upset about something."

This is the most therapeutic response. It acknowledges the client’s feelings without judgment and opens up communication. It allows the nurse to explore the client’s concerns, which is essential in providing appropriate care and support in a psychiatric setting.

D. "I can't call a doctor in the middle of the night unless it's an emergency."

While this statement is factually correct, it can come across as dismissive and could escalate the client's agitation. It does not acknowledge the client's emotions and might make the client feel that their concerns are not being taken seriously.

A. "How long has this been going on?" B. "Why do you think you are so anxious?" C. "Have you talked to your parents about this yet?" D. "It sounds like you're having a difficult time."

Correct Answer is D

Explanation

A. "How long has this been going on?":

While this question is important for gathering more information, it may come across as more investigative or less empathetic at this initial stage of the conversation.

B. "Why do you think you are so anxious?":

While it's important to understand the client's perspective, this response might come across as confrontational or judgmental. It's better to create an open and non-judgmental environment for the client to share their feelings.

C. "Have you talked to your parents about this yet?":

This response assumes that the client has parents to talk to and may not be relevant for all clients. It's also important to establish trust and rapport with the client before asking about their support network.

D. "It sounds like you're having a difficult time.":

This response is empathetic and validating. It acknowledges the client's feelings without making assumptions or demands, creating a supportive environment for further discussion.

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A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

Nursing Test Bank

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