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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale: Ice application induces vasoconstriction, which reduces swelling but does not evert inverted nipples. This action does not address the primary issue of nipple inversion preventing adequate latch.

Choice B rationale: Breast pump use creates negative pressure, drawing out the nipple. This eversion facilitates latching by providing a more prominent nipple for the infant's oral cavity to grasp effectively.

Choice C rationale: Supplemental formula feedings provide nutrition, but do not resolve the latching difficulty caused by inverted nipples. This can interfere with the establishment of the mother's milk supply.

Choice D rationale: Breast shields can aid latching, but they are most effective when used in conjunction with nipple eversion techniques. They do not directly address the underlying problem of inverted nipples.

A. Diapering will be provided since hospitalization is stressful to preschoolers. B. A retraining program will need to be initiated when the child returns home. C. A potty chair should be brought from home so he can maintain his toileting skills. D. Children usually resume their toileting behaviors when they leave the hospital.

Correct Answer is D

Explanation

The correct answer is choiced. Children usually resume their toileting behaviors when they leave the hospital.

Choice A rationale:

While it is true that hospitalization can be stressful for preschoolers, providing diapers may not be necessary. Regression in toileting is often temporary and related to the stress of the hospital environment.

Choice B rationale:

Initiating a retraining program immediately after returning home may not be necessary. Most children will naturally resume their previous toileting behaviors once they are back in a familiar and less stressful environment.

Choice C rationale:

Bringing a potty chair from home can be helpful in some cases, but it is not always practical or necessary. The child is likely to resume normal toileting behaviors once they are back in their usual environment.

Choice D rationale:

This is the correct answer because children often regress in their toileting behaviors due to the stress and unfamiliarity of the hospital environment.Once they return home, they typically resume their previous toileting habits.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is B

Explanation

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?

Correct Answer is D

Explanation

The nurse discovers that a male client has attempted suicide by slashing his wrists. Which action(s) should the nurse do first?

A client tells the nurse about jogging every day with the hope of losing weight and sleeping better. The client states that it takes hours to fall asleep at night and is experiencing fatigue and sleepiness throughout the day. Which action should the nurse implement?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention by the nurse?

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)

A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?