A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

The client talks constantly about the traumatic experience.

The client is constantly drowsy and sleeps 11-12 hr daily.

The client reports satisfying personal relationships with family and close friends.

The client is easily startled by loud voices.

Answer and Explanation

The Correct Answer is D

The client is easily startled by loud voices. Clients with posttraumatic stress disorder (PTSD) may exhibit hyperarousal symptoms, including exaggerated startle responses and hypervigilance. The client talking constantly about the traumatic experience is a possible finding in PTSD but not specific. The client is constantly drowsy and sleeping 11-12 hours daily is more associated with depression than PTSD. While the client may have satisfying personal relationships, it does not address the question of what finding to expect with PTSD, making choice C incorrect.

Reasons why the other choices are not answers:

Choice A, the client talking constantly about the traumatic experience, is a possible symptom of PTSD, but it is not specific to the disorder and may also indicate other disorders.

Choice B, the client being constantly drowsy and sleeping 11-12 hours daily, is more indicative of depression than PTSD and also does not address the question of finding expected with PTSD.

Choice C, the client reports satisfying personal relationships with family and close friends, does not address what finding is expected with PTSD, making it an incorrect answer.

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Correct Answer is D

Explanation

"I know you will do well living out in the community.". When a client expresses feelings of gratitude towards a nurse as they are about to be discharged, they are mostly affirming the therapeutic relationship between both parties. The nurse should acknowledge this affirmation clearly, warmly, and humbly, while encouraging the client's progress and independence. Choice D, "I know you will do well living out in the community" acknowledges the client's progress and offers encouragement.

Choice A, "Aren't you excited about being discharged today?" is a closed question that does not encourage the client's progress.

Choice B, "How do you feel about being discharged?" is not the best response because it is too broad.

Choice C, "I will send you a note in a few weeks" does not offer affirmation and encouragement to the client.

A. Identify support groups in the community for long-term treatment. B. Assist the client to identify negative effects of chemical dependency. C. Determine the presence and degree of suicidal risk. D. Refer client to mental health care provider for evaluation and treatment.

Correct Answer is C

Explanation

The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.

choice A and referring the client to a mental health care provider for evaluation and treatment.

choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.

choice B may be necessary but does not address the priority concern of suicidal risk.

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A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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