A nurse is caring for a patient who reports a recent increase in stressors.
Which of the following concepts should the nurse use to develop necessary context to both understand and deliver nursing care for this patient?
Right vs wrong
Justified vs unjustified
Good vs bad
Adaptive vs maladaptive
The Correct Answer is D
Choice A rationale
While understanding the concepts of right and wrong can be important in many aspects of nursing care, it may not be particularly helpful in this context. The patient’s stressors are not necessarily related to moral or ethical dilemmas.
Choice B rationale
The concepts of justified and unjustified might be relevant in some contexts, but they may not provide the necessary context to understand and deliver nursing care for this patient. These
concepts are more related to the evaluation of actions or decisions, rather than understanding a patient’s experience of stress.
Choice C rationale
Good and bad are subjective terms that can vary greatly between individuals. While these concepts might be relevant in some contexts, they may not provide the necessary context to understand and deliver nursing care for this patient.
Choice D rationale
The concepts of adaptive and maladaptive are directly relevant to understanding a patient’s response to stress. Adaptive strategies are those that help an individual cope effectively with stress, while maladaptive strategies are those that do not help, or that may even exacerbate the stress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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
Correct Answer is C
Explanation
Choice A rationale
Derealization involves feeling detached or disconnected from one’s surroundings, not changing details of a traumatic event.
Choice B rationale
Hypervigilance involves being overly alert or watchful, especially to potential danger, not changing details of a traumatic event.
Choice C rationale
Dissociative amnesia can involve difficulty remembering important information about a traumatic event, which can lead to inconsistencies in the child’s recollections.
Choice D rationale
Depersonalization involves feeling detached or disconnected from oneself, not changing details of a traumatic event.
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