A patient has been hospitalized after her house was destroyed in a hurricane.
She has spent two weeks in the intensive care unit and has now been transferred to the surgical floor for continued respiratory monitoring and completion of IV antibiotic therapy.
The patient reports a pain level of 2 on a scale of 0 to 10. She requests sleeping medication, explaining that she is haunted by distressing thoughts and memories of the house collapsing, which prevent her from sleeping.
She says, “I used to be so happy before all of this happened.
Now I can’t seem to get out of this funk I am in.”. She would also prefer a quieter area of the unit as she is currently near the nurses’ station and is disturbed by the noise.
After listening to the patient’s symptoms, the nurse suspects that she likely has:
Phobia.
Acute stress disorder related to traumatic stress exposure.
Hallucinations.
Separation anxiety.
The Correct Answer is B
Choice A rationale
Phobia is characterized by an excessive and irrational fear response. In this case, the patient’s symptoms do not indicate a specific fear, but rather general distress and intrusive thoughts related to a traumatic event.
Choice B rationale
The patient’s symptoms, which include distressing thoughts and memories of the house collapsing, difficulty sleeping, and a significant change in mood, are indicative of acute stress disorder related to traumatic stress exposure. Acute stress disorder can occur within a month of experiencing a traumatic event, like a natural disaster.
Choice C rationale
Hallucinations involve perceiving something that is not present. The patient’s symptoms do not include any indications of hallucinations.
Choice D rationale
Separation anxiety involves excessive fear or anxiety about separation from those to whom the individual is attached. The patient’s symptoms do not indicate a fear of separation, but rather distress related to a traumatic event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Responding to the code while performing tracheostomy care could potentially put the current patient at risk. The nurse has a responsibility to ensure the safety of the patient they are currently caring for.
Choice B rationale
Closing the room door does not address the immediate needs of either patient and does not contribute to the safety or care of the patients.
Choice C rationale
Calling for an assistant is the most appropriate action. This allows the nurse to ensure the safety of the current patient while also allowing for a response to the code blue. The assistant can continue care for the current patient, or the nurse can delegate the assistant to respond to the code while the nurse continues care for the current patient.
Choice D rationale
Finishing the procedure could delay response to the code blue, potentially putting the other patient at risk.
Correct Answer is A
Explanation
Choice A rationale
The patient’s history of asthma, previous hospitalizations for asthma-related symptoms, and the current presentation of difficulty breathing and wheezing suggest that she is likely experiencing an asthma exacerbation related to environmental factors. Asthma is a chronic condition that can cause symptoms such as wheezing, shortness of breath, and chest tightness, which the patient is currently experiencing. Environmental factors such as allergens, air pollution, and changes in weather can trigger asthma symptoms.
Choice B rationale
While smoking is a major risk factor for COPD, the patient denies smoking. Additionally, COPD is more common in older adults, and the patient is only 22 years old. Therefore, it is less likely that her symptoms are due to COPD.
Choice C rationale
Pneumonia is typically associated with additional symptoms such as fever, cough with phlegm, and chest pain. The patient’s symptoms do not align with a typical presentation of pneumonia.
Choice D rationale
Tuberculosis is a bacterial infection that typically presents with a chronic cough, weight loss, and night sweats. The patient’s symptoms do not align with a typical presentation of tuberculosis.
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