A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

Increasing sense of attachment to others

Increasing feelings of anger

Constant need to talk about the event

Sleeping 12 hr or more each day

Answer and Explanation

The Correct Answer is B

Increasing feelings of anger are a common symptom of PTSD after a sexual assault, as survivors may feel violated, powerless, or betrayed by the perpetrator or others. Anger can also be a way of coping with fear, anxiety, or guilt that may arise from the trauma.

Choice A is not correct because the increasing sense of attachment to others is not a typical response to sexual assault. Survivors may experience difficulties in trusting or relating to others, especially those who remind them of the assault or who do not support them.

Choice C is not correct because the constant need to talk about the event is not a characteristic of PTSD. Survivors may avoid thinking or talking about the trauma, as it can trigger distressing emotions or memories. Some survivors may choose to share their experiences with others, but this does not indicate PTSD.

Choice D is not correct because sleeping 12 hr or more each day is not an expected finding of PTSD after a sexual assault. Survivors may have trouble falling or staying asleep, or experience nightmares or flashbacks that disrupt their sleep quality. Sleeping too much can also be a sign of depression, which can co-occur with PTSD.

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Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

"Stay with the client during meals and for 1 hr afterward," and "Monitor the client's weight daily after first voiding." These are important interventions for clients with anorexia nervosa, as they can help to prevent complications such as dehydration and electrolyte imbalances.

Choice B, "Give the client a weight gain goal of 4 to 5 lb per week," is not an appropriate intervention, as it can be overwhelming and may promote unhealthy weight gain.

Choice D, "Encourage the client to keep a diary of daily food intake," may be helpful for some clients, but is not a priority intervention.

Choice E, "Offer specific privileges for sustained weight gain," is not an appropriate intervention.

A. Initiate one-to-one nursing observation. B. Make a contract with the client for weight gain. C. Administer the Hamilton depression scale. D. Review the client's toxicology laboratory report.

Correct Answer is A

Explanation

initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.

Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.

Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.

Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.

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A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on an inpatient unit is caring for a newly-admitted client who has anorexia nervosa. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

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Correct Answer is A

Explanation

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