The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.

For each client statement, click to highlight the statement(s) below that require follow up teaching by the nurse.

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

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

I can learn to manage my thoughts better through therapy.

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

This diagnosis means that I am crazy.

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

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

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

I can learn to manage my thoughts better through therapy.

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

This diagnosis means that I am crazy.

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

Answer and Explanation

The Correct Answer is ["A","E","F"]

A) Correct- The client's statement suggests a misconception about the progression from acute stress disorder (ASD) to post-traumatic stress disorder (PTSD). While ASD is an initial response to trauma, it doesn't necessarily indicate a high risk for developing PTSD. The nurse should provide education about the differences and the various factors that influence the development of PTSD.

B) Incorrect- This statement reflects the client's proactive approach to using holistic approaches like meditation to manage symptoms. Meditation and other relaxation techniques can be beneficial for managing stress and anxiety related to the traumatic event.

C) Incorrect- This statement reflects the client's motivation to learn how to manage their thoughts better through therapy. Therapy can be highly effective for addressing trauma-related distress and helping clients develop coping strategies.

D) Incorrect- This statement reflects the client's recognition that their response is shared by many people in similar situations. Validating the client's experience and normalizing their feelings can be therapeutic.

E) Correct- This statement reflects a common misconception and stigma associated with mental health diagnoses. The nurse should reassure the client that a diagnosis of acute stress disorder does not equate to being "crazy" and provide information about the nature of the disorder and available treatments.

F) Correct- The statement implies a potential pessimistic outlook on treatment. While medication might be part of the treatment plan, it's important to emphasize that treatment approaches are individualized. Encouraging an open dialogue about various treatment options, including therapy and coping strategies, is essential.

Nursing Test Bank

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Correct Answer is ["A","B","D","F"]

Explanation

A.Correct- The nurse should provide the parents with the phone numbers and websites of local organizations that offer support and counseling for families who have experienced a traumatic event. The nurse should also encourage the parents to seek professional help if they feel overwhelmed, depressed, or anxious.

B.Correct- Educating the parents about pool safety is crucial to prevent future accidents. This information can include guidelines for supervision, barriers, and measures to prevent drowning incidents.

C.Incorrect- While it's important for parents to be aware of the seriousness of child neglect, including this information in pre-discharge education might not be the most appropriate time, especially if the child is showing only minor signs of impact from the incident. This could increase their guilt and distress and damage the therapeutic relationship. The nurse should focus on providing support and education, not judgment or punishment.

D.Correct- The nurse should advise the parents to schedule a follow-up visit with the child's pediatrician within a week of discharge. The nurse should explain that the pediatrician will monitor the child's recovery and check for any signs of complications, such as brain damage, infection, or lung injury.

F. Correct- Assessing the parent's coping skills can help identify if they are dealing with any emotional stress or trauma related to the incident. Providing appropriate support or referrals if needed can be beneficial.

A. Take the child's pulse B. Place a cervical collar on the client C. Look for any open wounds D. Call child protective services E. Determine if the child's airway is clear F. Start a peripheral intravenous line

Correct Answer is ["A","B","C","E"]

Explanation

A) Correct- Assessing the child's pulse helps determine their cardiac status and whether they have a detectable heartbeat. This information is essential for deciding the appropriate interventions.
B) Correct- Placing a cervical collar is necessary if there is any suspicion of cervical spine injury due to the fall or submersion. This action helps stabilize the neck and prevent further damage to the spine.
C) Correct- Checking for open wounds is important to assess for potential sources of bleeding or infection that may require immediate attention.
D) Incorrect- While child safety is important, the immediate priority in this situation is assessing and stabilizing the child's medical condition. Child protective services may be involved later if there are concerns about the circumstances surrounding the incident.
E) Correct- Assessing the airway is of utmost importance to ensure that the child can breathe. In cases of near-drowning, ensuring a clear airway is crucial for oxygenation.
F) Incorrect- While establishing intravenous access may be important for certain interventions, it is not one of the immediate priorities in this situation. Ensuring the child's airway, breathing, and circulation take precedence.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits here What should the nurse include in pre-discharge education for this child's parents? Select all that apply.

Correct Answer is ["A","B","D","F"]

Explanation

Review H and P and nurse's notes. What are the first four actions that the nurse should take?

Correct Answer is ["A","B","C","E"]

Explanation

The nurse is caring for a client newly diagnosed with emphysema. The nurse should prioritize which potential complication?

An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?

In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?

An adult client is admitted for severe pain in his side and back and is sent for an intravenous pyelogram. Which report from the client is the earliest indication to the nurse that the client is experiencing an adverse reaction to this procedure?

The nurse discovers that an older client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply.)