A nurse is responding to a parent of an adolescent who was recently diagnosed with posttraumatic stress disorder following a sexual assault.
The parent states, "My child ignores curfew, is hanging out with a rough crowd, and has been experimenting with drugs.
Why would they be doing this?" Which of the following responses should the nurse make?.

Pill rolling movements and drooling.

"It is very frustrating when children misbehave.

"This must be a difficult time for you.

"This is normal behavior for an adolescent.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

While it’s important to address the parent’s concerns, this response does not provide the parent with information about why their child might be exhibiting these behaviors.

Choice B rationale:

This response does not address the parent’s question about why their child is exhibiting these behaviors.

Choice C rationale:

This is the best choice because it provides the parent with information about why their child might be exhibiting these behaviors.

Choice D rationale:

This response minimizes the parent’s concerns and does not provide them with information about why their child might be exhibiting these behaviors.

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Correct Answer is B

Explanation

B)Depersonalization: Depersonalization, which involves feeling detached from one's own body or thoughts, is a key symptom of panic-level anxiety. It occurs when the client feels as though they are observing themselves from outside their body or disconnected from reality, often as a coping mechanism to manage the intense distress experienced during a panic attack.

A. Ask the client about the lethality of their plan B. Encourage the client to focus on the positive aspects of life. C. Reassure the client that everything is going to work out. D. Allow the client time alone to self-reflect.

Correct Answer is A

Explanation

Choice A rationale:

Asking the client about the lethality of their plan is the most appropriate action. This allows the nurse to assess the immediate risk to the client’s safety.

Choice B rationale:

Encouraging the client to focus on the positive aspects of life may be helpful in some situations, but it does not address the immediate safety concern.

Choice C rationale:

Reassuring the client that everything is going to work out may provide temporary relief, but it does not address the immediate safety concern.

Choice D rationale:

Allowing the client time alone to self-reflect is not appropriate in this situation as it could increase the risk of self-harm.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on an inpatient mental health unit is caring for a client who is experiencing panic level anxiety. Which of the following findings should the nurse expect?.

Correct Answer is B

Explanation

A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?.

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing delusions, hallucinations, and alterations in speech. Which of the following medications should the nurse anticipate the provider to prescribe?.

A nurse is caring for an adolescent who is experiencing recurring manifestations of influenza. Which of the following phases of Selye's General Adaptation Syndrome (GAS) explains the possible cause for the adolescent's manifestations?.

A nurse is planning discharge for a client who has schizophrenia and reports "I don't have a place to live.”. Which of the following referrals should the nurse request from the provider?.

A nurse is reviewing assessment findings for a 9-year-old child whose family home was destroyed in a wildfire. The nurse should identify that which of the following behaviors is related to the traumatic experience?.

A nurse is caring for a client who is experiencing excessive anxiety and worry in response to a variety of circumstances and is unable to control their sense of worry. The nurse should identify that these manifestations indicate which of the following?.

A charge nurse in a mental health facility is teaching a newly licensed nurse how to perform an Abnormal Involuntary Movement Scale (AIMS) assessment on a client. The charge nurse should identify that the AIMS assessment is used for which of the following conditions?.

A nurse is caring for a client who ingested a selective serotonin reuptake inhibitor and St. John's Wort. Which of the following findings should the nurse identify as being consistent with serotonin syndrome?.