Exhibits
For each client statement, click to highlight 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."
"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."
The Correct Answer is ["A","C","D","F"]
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
While completing a thorough room search to remove potential self-harming objects is important, it should follow the immediate need for monitoring and intervention.
Choice B rationale:
Providing time alone in the client's room may not be appropriate when the client is exhibiting signs of distress and increased risk.
Choice C rationale:
Closely monitoring the client and having staff intervene as needed (Choice C) is the most important intervention in this situation. Clients with a history of self-mutilation who display signs of increased tension and agitation may be at higher risk for engaging in self-harming behaviors. Close observation and intervention can help prevent self-harm and ensure the client's safety.
Choice D rationale:
Giving firm, consistent expectations is important in the overall care plan but may not be effective in acute situations where immediate monitoring and intervention are required.
Correct Answer is C
Explanation
Choice A rationale:
Preoccupation typically involves excessive thoughts or worries about a particular topic and may not directly manifest as physical symptoms like numbness and tingling.
Choice B rationale:
Reexperience often refers to the reliving of traumatic events through flashbacks or intrusive memories and is more closely associated with conditions like post-traumatic stress disorder (PTSD).
Choice C rationale:
Somatization refers to the expression of psychological distress through physical symptoms. In this case, the client's numbness and tingling on the right side of the body may be somatic symptoms related to the psychological distress and grief experienced after the spouse's death.
Choice D rationale:
Disorganization is not typically associated with physical symptoms like numbness and tingling. It may relate to cognitive or emotional difficulties but not to these specific physical sensations.
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