Exhibits

For each client statement, select the statement(s) below that require follow-up teaching by the nurse.

"This diagnosis means that I am crazy."

"I can learn to manage my thoughts better through therapy."

"I can use holistic approaches like meditation to help my symptoms."

"Many people have the same response to a stressful situation as I am having right"

"I am at high risk for post-traumatic-stress disorder because I have acute stress disorder"

"I will probably need to be on medication for the rest of my life."

Choice A rationale:
This reflects a potential misunderstanding about the diagnosis and may contribute to stigma. The nurse should provide education and clarify that having acute stress disorder or similar responses to trauma does not mean the client is "crazy."

Choice B rationale:
This statement reflects a positive attitude toward therapy and self-improvement. There is no immediate need for follow-up teaching in this statement, as it aligns with the potential benefits of therapy for coping with trauma.

Choice C rationale:
This indicates the client's interest in holistic approaches, which is positive. However, the nurse should provide information and guidance on the use of such approaches in conjunction with other treatments.

Choice D rationale:
This suggests that the client may believe her response is typical. The nurse should provide education about the variability in individual responses to stress and trauma.

Choice E rationale:
This statement shows an understanding of the relationship between acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). While it's true that having ASD can increase the risk of developing PTSD, this statement does not require immediate follow-up teaching. However, the client should receive ongoing education about managing and preventing PTSD

Choice F rationale:
This raises concerns about the client's expectations regarding the duration of medication. The nurse should provide information about the intended duration of medication and the importance of ongoing assessment and follow-up with healthcare providers.

Choice A rationale:
This order is useful to evaluate the client's electrolyte levels, renal function, and acid-base balance, as she has ERSD and missed her dialysis session. She may have hyperkalemia, metabolic acidosis, or uremia, which can affect her cardiac and neurological status.

Choice B rationale:
This order is helpful to assess the client's cardiac structure and function, as she has a history of CAD and HTN and may have developed heart failure or valvular disease.

Choice C rationale:
This order is beneficial to rule out any intra-abdominal causes of the client's nausea and poor appetite, such as infection, obstruction, or bleeding.

Choice D rationale:
This order is necessary to identify any possible source of infection or sepsis, as the client has been ill for 3 days and has a history of diabetes, which can impair her immune system.

Choice E rationale:
This order is important to assess the client's cardiac and pulmonary status, as she has a history of CAD and is presenting with chest discomfort and lightheadedness, which could indicate a cardiac event or pulmonary edema.

Choice F rationale:
This order is essential to monitor the client's heart rate and rhythm, as she has a history of CAD and HTN and is at risk for arrhythmias, ischemia, and infarction.

Choice G rationale:
This order is important to evaluate the client's hematological status, as she has ERSD and may have anemia, leukocytosis, or thrombocytopenia.

Choice H rationale:
This order is crucial to obtain a baseline of the client's cardiac electrical activity and to detect any signs of acute coronary syndrome, such as ST-segment elevation or depression, T wave inversion, or Q waves.