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 B
Explanation
Choice A rationale
Hematocrit is a measure of the proportion of red blood cells in the blood. While it can be affected by various conditions, it is not the most relevant lab value to check when purulent drainage is noticed at a postoperative patient’s dressing site.
Choice B rationale
Neutrophil count is a measure of the number of neutrophils, a type of white blood cell, in the blood. An elevated neutrophil count can indicate an infection, making it the most relevant lab value to check in this scenario.
Choice C rationale
Platelet count is a measure of the number of platelets in the blood. While platelets play a crucial role in blood clotting, they are not directly related to infection and therefore not the most relevant lab value to check in this scenario.
Choice D rationale
Serum sodium level is a measure of the amount of sodium in the blood. While it can be affected by various conditions, it is not the most relevant lab value to check when purulent drainage is noticed at a postoperative patient’s dressing site.
Correct Answer is {"dropdown-group-1":"C"}
Explanation
Based on the client’s history and physical, the nurse notes that this postpartum client is most at risk for developingC. Postpartum hemorrhage.
The client’s laboratory results show a decrease in red blood cells (RBC), hematocrit, and hemoglobin levels, which are all signs of blood loss. Additionally, the nurse’s notes mention moderate lochia rubra with small clots, which could be a sign of postpartum hemorrhage. The firm fundus at the umbilicus is a good sign, but the blood loss output and decreased blood values indicate that the client is at risk for postpartum hemorrhage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
